Dental Health & Education P8

Student: [inaudible]

The toothpaste? Original formulation perhaps. Original formulation Colgate. There’s no magic in toothpaste as long as it has the fluoride in it. That’s the biggest benefit in a toothpaste. It’s the soap and the fluoride.

Student: What if you’ve got where your gums have receded and maybe there is some sensitivity there because enamel [inaudible]

You can. You cover those if it gets you screaming. I had to put fillings over that exposed tooth structure. Normally we try using potassium…it’s in the toothpaste, desensitizing toothpaste… Sensodyne. It’s a potassium ion… potassium chloride… my mind…it escapes me but it’s a…potassium nitrate. Forms a plug at the end of the tubule. Your tooth is an enamel, enamel covering with the dentin underneath it. The dentin is just a bunch of hallowed pipes. It’s just a bunch of hollowed tubes with the cell body in the middle of that tube and so if the end of the plug of that tube becomes open, anything that rubs across it or osmotic gradients change – a really sugary solution or really acidic solution, it tugs on that cell body and it transmits impulse to the tooth. So if you plug up that tubule, then that little cell body is happy. That’s where the desensitizing toothpaste is trying to form a plug in that tubule. You can do it with fluoridine, you can do it with potassium nitrate.

Student: How long does it take, I think you said acid is what starts eating away at the tooth? How long does it take for it to?

17 minutes.

Student? 17 minutes? And acid can form that quickly?

That quickly. So if you have something sugary and acidy, you got to brush your teeth immediately. An hour later, too late.

Student: So this brushing twice a day really doesn’t make sense if you are going to eat anything sugary. You’re going to have to brush right afterwards or rinse your mouth.

Rinse your mouth. When you’re brushing twice a day, you’re trying to brush the plaque off your teeth. So if there’s no plaque on your teeth then there’s no bacteria and sugar is not going to be harmful.

Student: And how long does it take for the plaque to build up?

24 hours.

Student: [inaudible] If you don’t have the plaque buildup do you get the acid?

There’s no acid. The plaque doesn’t form the acid. Now if you have a really acidic drink. But plaque takes in the sugar and uses a Krebs cycle and byproduct of that is acid. That’s the acid that demineralized the tooth. And then when it demineralizes the tooth, it gets soft and the bacteria can penetrate in and then the worse it gets the faster it gets worse.

Student: So you should be okay if you are brushing twice a day and getting rid of the plaque?

If you’re getting a hundred percent of it off but nobody gets 100 percent of it off.

Student: So what is plaque?

Plaque is a biofilm. It’s a biofilm. It’s a bacteria and a bunch of polysaccharides that the plaque…that the bacteria excretes and becomes adherent. It becomes a matrix for more bacteria to form and grow. It becomes its own environment to harbor itself.

Student: Almost like a barnacle.

When it calcifies from the minerals in your saliva, then we call it calculus. But plaque is a biofilm. I don’t know if you’ve ever seen the inside of the pipe that’s got that slime layer on it? That’s a biofilm there. that’s just loaded with bacteria that populated that surface. Well, that’s what happens in your mouth when you get a biofilm. And it’s mostly strep mutant. And there’s different strains of strep mutant, and some strains are more virulent and are more decay producing than others. Brushing twice a day helps with the plaque forming. 24 hours…you dislodge it, knock it off your tooth, just not going to get back on it for 24 hours. But you literally… if we all brushed our teeth for 4 minutes and we took disclosing tablets, chewed them up and we looked in each other’s mouths we ‘d go “Whoa!” There is still biofilm layer on there. It’s difficult. It’s not easy to clean your teeth. But so, okay. On to bisphosphonates: Actonel, Fosamax, Boniva and those drugs. Active osteonecrosis of the jaw. ONG. It’s a significant problem. The drug companies report that it happens very, very, very, rarely. 1 in 100,000 patients. well, if that was the case, Santa Maria has 100,000 people living in it. My oral surgeon would see only 1 case of it. Well that ain’t true. He sees quite a few cases. In osteonecrosis of the jaw…In a treatment of osteoporosis basically the drug you take stops bone turnover. When you turnover bone, you reabsorb bone and you lay more of the bone down. Well, to build bone, it stops the bone resorptive process. So you are getting bone deposition process so the bone density goes up. The key question is, is this bone any stronger? Or is just like adding a plaster veneer to a broken down wall? It looks good but it’s still a weak bone. That’s what I always wondered. Just because it’s dense bone does it really mean less prone to fracture? But that’s a whole different discussion. The unique thing about… there’s a difference in the mouth. The jawbones turnover 17 times more frequently than your femur. So this drug because of the way it works, it gets concentrated in jawbones. So it will stop bone turnover. It stops. So if you extract a tooth of somebody who has been on Fosmax or Boniva or Actonel for a period of time that wound never heals. And when I mean never heals I mean never heals. And it’s nasty and it’s ugly and it smells and it looks terrible and gets painful and it has to go in and bigger areas die and they go in and scrape out that area and it never heals back in. Hyperbaric oxygen doesn’t work on it. They’ve gotten a few cases to resolve but once it’s dead gone daddy gone there’s no turnover. It will never heal. So these patients are left with unhealed wounds in their mouth and sections of their jaw that will die and sometimes they cut that section out and put a graft in and then that section dies and it’s just…it’s horrible. It’s really debilitating. And sometimes it’s just a small one and it just never heals. Patients that have been on the bisphosphonates therapy for a period of time, before we do sometimes even a deep cleaning, they have to go off of it for a while. There’s a bone turnover marker. The CTX bone marker. I used to know what the CTX stood for. But it’s a bone turnover marker that not too many people are familiar with. And if I ordered the test, the insurance company won’t pay for it. So I have to have a physician order it. You know, and I hate to say it but I had physicians asking go “I don’t know what it is. What is it?” So just order and it’s got to be above 150 otherwise we can’t take out a tooth from this patient, we can’t do periodontal surgery, we can’t do deep cleaning. They have to go off the drug for a period of time and let the bones start turning over in the mandible and the maxilla and lets remodeling occur. And if the count seems to be above 150 on the CTX test then it’s safe. It’s safe. And then, the very potent  drugs like that are used in the treatment of lymphoma and leukemia, bone cancers and those patients, once they have [inaudible] there are real problem. There’s a patient who gets sent to me and say “Dr Kirk you got to do all the dentistry on this patient in 2 weeks” Because in 2 weeks they are going to start their Zometa and after that you can’t touch them because they are worried about osteoporosis of the jaw.

Student: These guys who keep losing more and more bones once they go off their drugs to go of these drugs would they heal back or they are just too far?

Once the bone is dead, it’s dead. It does not a remodel. It’s a osteonecrosis of the jaw. And the Actonel Fosmax companies kind of got hit blindside with it and then they said “oh, these dentists are nuts!” It’s obviously the whole osteoporosis therapy regime has to be followed and that for the physician and their management. But there comes a point where if they need dental work they have to go off the drug for a period of time. They have to take a drug holiday. And let that CTX score bounce back, the bone turnover marker got to where they are turning over bones so when I take out a tooth that wound is going to heal because wounds heal, bones heal by remodeling. If you stop the remodeling process then it will never heal. And once you think of mandible and maxilla, it turns over so much faster the drug ends up being concentrated in there and it literally stops bone turnover.

Student: Do you know how long does it need to keep the person off?

3 months.

Student: Kind of worried about those once a year shots.

Student: Most of people that are taking this stuff shouldn’t be taking it.

I can’t speak to that. I don’t… I wonder about…

Student: It’s called the broken bones business.

I wonder about, just because you’re plastering more bone…Because I was thought, you were thought, you know, bone remodels and bone remodels because the structure of the bone breaks down and factures and breaks down. So it always has to be rebuilt otherwise the bones get brittle and will break. So if you stop the bone remodeling process and you’re not breaking down and repairing that broken bone, you’re just slathering on more calcium hydroxylapatite over broken bone, are you really strengthening the bone enough to reduce hip fraction. The data they have shows that it does significantly reduce the risk of hip fraction. So I got to believe that it works. So, you know, that’s… I’m no physician. I just wonder about it.

Student: Been quite a few articles on it.

I just wonder about that treatment. Maybe… what’s your treatment? Would tey just blast you one time or is it just slow release drug?

Student: I don’t know. It seems scary if you have a problem.

You can’t stop it.

Student: Even if they stop Fosmax you still have that effect for years.

Student: [inaudible] something like radiation…

It’s just once a year so. Maybe in a sense it’s better because it could be that is stops bone turnover for 3 to 4 months and that [inaudible] build up and then slowly washes out and lets bone remodel again and build and build and then you get another injection and let the bone density fill back up. So maybe that…it could be working that way too.

Student: Current theory is that if you eat too much protein that the protein because of acidic amino acids then the body needs more to counteract the acidity so then it starts pulling  calcium out of the bone to neutralize the amino acidity. Wonder is why countries like Western [inaudible] you get more osteoporosis than in Africa and Asia. They have much less osteoporosis because they mostly eat fruits and vegetables. Very rarely fish and meat. [inaudible] 500 mg of calcium. Why we need it so much is we need calcium to neutralize all these amino acid acidity but in Africa and Asia [inaudible] You see very little osteoporosis. You need some physical activity. But when you leave Asia and come here within a generation [inaudible] OS the diet is they key of preventing.Things like that.

I’m sure this has a lot to do with it. Bisphosphonate related osteonecrosis of the jaw…that’s why you’ll see on those commercials on TV. If you have jaw problems call your dentist right away. That got kind of on there because we started raising…but if you have jaw problem, it’s too late. “I got a wound here doc.” Well, guess what? It’s not like you can take a dive in hyperbaric oxygen chamber and it’ll heal. There’s osteoradio necrosis. Necrotic bone because of radiation exposure to kill a tumor. That bone will die but you can get it to come back and heal if you go into hyperbaric oxygen. High oxygen level. For a prolonged period of time you can get this bone to heal. Not so with the osteonecrosis of the jaw. Hyperbaric oxygen chamber does not appear to heal which is a scary thing, which means that’s it. And Dr Petrovski, he’s got a number of patients. When I say number…probably 10 to 15 Just one oral surgeon in town. The there’s his partner who’s got some. Then there’s the other surgeon in town. So you can’t tell me it’s 1 in a 100,000. It’s much more than that. But anyway. I hope you guys didn’t get too bored this evening and had a good time. I enjoyed myself.

Student: Any subject that we should’ve covered yet?

We hit everything. If we had any more subjects I would put them all to sleep.

Student: Here’s an article for you. I just haven’t looked at it yet. High school sweet tooth.

Yeah, that’s a big problem. All the sodas and sport drinks in school. The kids just suck on those things all day and they sip on them and…I got a high school athlete right now. I’m just doing a whole bunch of fillings on him and I’m just trying to figure out where is coming from, where is the sugar source coming from. And I do dietary questionnaire…

Dental Health & Education P7

That’s what it was because those patients got their dental work done and they were getting preventative care so the exposure and the loss that the dental insurance company was taking was a lot less because those patients once they got them up to speed, and they got them up to speed at lower coverage rate. When they were getting those crowns and those fillings done, they were at 60%-70% percent [inaudible] everybody else. Now they’re up to speed and they bounce up to  100%, you’re not really going to need anything. They don’t need it now.  But if a tooth does break at that point, you got your crowns covered at 100%. I used to know more about the insurance in practice… I completely devoid myself of that for the reason when I get into diagnosing cases and what needs to be done and what can be done way. There’s always different ways to skin a cat. The variability is how well it functions and how well it looks and then gets to how much it costs. So I try to stay away from the financial aspects so that I don’t start diagnosing patient’s pocketbook. I don’t start assuming what’s best for you because I don’t think you can afford that implant now. So I’ll tell you we’ll do a partial. Let’s send off authorization for partial. Then we get authorization for partial, you get a partial. You are none wiser that I could’ve sent off an authorization for implants abut I didn’t think you can afford the implants so I didn’t ask. I didn’t author it. Your own prejudices start to play and, you know, you start diagnosis the patient’s pocketbook which is not what you’re there for. You’re there to diagnose what’s going on, tell the patients what’s going on, tell them their options and tell them the risks, benefits and advantages of each of those options so the patient can make a fair assessment of what’s best for them and what they want to do and then we do it. That’s the way ideally I would like the interaction between myself and the patients to work. They come to me, I’ll diagnose the problem, then I’ll come up with various solutions, various materials we can use, ways we can do it and what’s good and bad about each of those different approaches and then the patient gets to decide and hopefully I have imparted enough knowledge in the consultation that they can make an informed decision. The idea of informed consent. They actually know what they are agreeing to. “Yeah I’m going to do that tooth implant” “It’s the $12,000” “Yeah, that’s the tooth implant I want to.” But do they really understand that they are going to be going to the oral surgeon, they’re going to have a bone graft, they are going to…you know, all this is going to happen and then they’re going to get their 6 teeth back, in the front. Or do they just want “You know what doc, I don’t want to come in and out of the doctor. I’m sick and tired of it. I just want teeth up there as fast as possible.” We say “Okay we can do that as fast as possible. We can make you a partially very quickly. But the downside is you can’t eat an apple.” “I don’t care doctor. I’ve been chewing like this way I am now. I just want a [inaudible]. “Okay.” You know that there’s something better, you opt not to have it. They make an informed decision. But if you don’t tell them the downside, tell them what’s better about implants then they’re not making an informed consent. I spend a lot of time, as you’ve probably figured out, talking.

Student: [inaudible] what you want to do is get them young and keep them cleaning their teeth and flossing, taking care of their teeth and coming in for the visits because preventing…

My goal is and I’ve seen it fortunately a number of times. Little, tiny kids come in, they are two years old and they come in and we start them in the dental office and now they’re 25 years old and married and they have no cavities and it’s just like “Wow, I pulled it off! I got them through the cavity prone years. I got them through high school, I got them through college and they don’t have decay.”

Student: Are you still making money on those guys?

Well, you know, yeah, I do. They come in for regular visits. I tell the 14, 15 year old kids that are at that point where they are kind of rebelling against throw away and they’re not brushing and flossing, I say “You know, you can save yourself” …cause they’re still at that point they understand money. “You know if you take care of your teeth, you get through the next 10 years without a cavity, you’re going to save yourself enough money by the time you’re 40 you’ll go to Europe.” Because if you do a couple of root canals, a couple of crowns, you lose a tooth, do a bridge, have fillings replaced… By the time you’re 40 you’ve probably popped in about 6 or 7 thousand dollars to the dentist.

Student: At least.

Yeah. So dentistry is expensive. Dentistry is expensive.

Student: And the insurance coverage is not up to par.

They coverage has…it’s the yearly maximum. The yearly maximum of dental benefits in the 60’s was at 1000-1500 dollars. In the 60’s. It’s gone up maybe $500. Let me tell you…the premiums have gone. Yeah, so I don’t know what…So they haven’t increased their risk of exposure because the maximums are still the same was in the 60’s. The maximum hasn’t gone up so… and preemies have gone up. Where is this money going? But that’s…

Student: So we have teeth but we can’t afford food.

Student: Sonicare use and you were going into Fosamax.

Oh, yeah. I like Sonicare toothbrushes. Everybody goes “What tooth brush do you use?” Costco’s is the best deal in town. Costco sells them cheaper than I can buy them directly from the company. We would buy them for patients and I generally stock one or two in the office just for patients.

Student: They are like vibrating toothbrushes.

Yeah, they work like the sonic cleaning instrument that hygienists use.

Student: For some reason I seem to like to use the toothbrush first and then the Sonicare.

They are sonic technology. I don’t [inaudible] it’s 4000 Hertz vibratory cycle so the bristles are just vibrating. It’s like a bumble bee in your mouth.

Student: It almost seems like when it’s on your gums maybe it’s helping anything that might be underneath it.

The great thing about the brush that I like is very soft bristle brush. So when you get it working, you know, when I use little circles, brush up into the gum line so those bristles hit the side of the tooth and go up into that crevice of the tooth and gum so that you’re trying to get those bristles into that periodontal crevice and keep it clean. And they also get in between the teeth as far as they can. But it doesn’t matter what toothbrush you use, what technique you use, how long you brush your teeth. It doesn’t get in between your teeth. That idea of the vibratory action of the bubbles breaking off the stuff off tooth…That’s pure hogwash. You got to floss. If you don’t floss it’s like not brushing half of your teeth. Cause half the surface of the teeth face each other. And you’re really not getting the plaque off those teeth. So flossing once a day but brush twice a day, floss once a day. That’s the general recommendation. Now when you start adding some sugar meals in there, you get to add some brushing and flossing.

Student: Why is now brush twice a day, it used to be brush after every meal?

I say twice a day because I’m being…because brushing after every meal is practically impossible.

Student: Would it be too abrasive if you brushed after every meal. Would it be a problem?

No. The toothpaste now…we have a very non-abrasive toothpaste. If you’re getting into the smoker’s whitening toothpastes then they are abrasive. Also, we use soft bristle to brush now. It would be hard pressed to find a hard bristle brush.

Student: Some seem just stiffer. [inaudible] you recommend a soft?

Soft. The softer brush, the softer the touch. Because it’s the tips of bristle that do the action. So if you press hard with a soft brush, if you’re used to using a firm brush, and you press hard with a soft brush, the bristles just all bend back and the tips of bristles aren’t brushing anything. “They don’t work. I can get anything clean with this soft brush.” Because they are using too hard touch.

Student: Recommendations for some mouth washes?

Listerine is good one. But I like…if you’re going to rinse with mouth rinse with the one with the fluoride. Like Act or Fluorigard. Listerine is nice antiseptic but if you’re…works great in a petri dish. It kills the germ causes bad breath. It’s got to sit there for a minute. [inaudible] without swishing it to the other side for a minute. It burns! But it’s a good antimicrobial mouth rinse. But people get into the…forget that gum disease is below the gum line. If you have gum disease you can rinse 20 times a day with Listerine, it does no good because it’s all below the gum line. You can’t get the water up there [inaudible] doesn’t work. The only thing that was found to get that stuff under those gum line pockets is those trays with gaskets. The Peri Tray. The guy who designed those trays, came up with the idea, was very smart in marketing. He got it FDA licensed as a medical device. So only FDA labs can provide it and it is patented. And you have to be licensed by him to use them. So you basically have to pay him royalty and take a certain vocational course to learn how to use them. And there’s the FDA labs, the two…there’s two FDA labs, certified labs that fabricate the trays. The gasket set up on them and how they wax them, it’s a fairly…I can see why he just couldn’t just turn it to a laboratory technician and make it but I wish I had thought of it.

Student: Which brands do you recommend?

Of mouth rinse? Act and Fluorigard. Act A.C.T. That’s Crest brand. The other one is Fluorigard. Act, just A-C-T. F-L-O-U…how do they spell it? It’s just fluoride guard is what they are trying to say. Those two fluoride mouth rinses it’s the…[inaudible] Crest Total mouth Rinse, it’s another one. It’s trying to get everything: antimicrobial, anti-tartar formation, and all those into one and fluoride. You want a mouth rinse with fluoride. And toothpaste, you might as well brush with soap. It doesn’t do any…it’s just soap. Toothpaste is just soap with a little bit of abrasive in it and fluoride and breath fresheners. There’s nothing magic about toothpaste.

Student:  Which one do you like best though?

The toothpaste? Any brand that has ADA seal on it because that brand has been shown to have fluoride actually in the toothpaste and it has to be submitted…

Student: Which one?

It has a ADA, American Dental Association seal of acceptance. Because they’re tested and have to show that they have fluoride in them, active fluoride at the levels that are prescribed. Because a lot of the toothpastes that claim to have fluoride in them don’t have any fluoride at all that would be in the form of…

Student: Is the amount of the abrasive in toothpaste limited, that they can’t exceed a certain amount?

No. there’s something like Topol toothpaste. That stuff is very abrasive. In the Topol smoker’s toothpaste. But the toothpaste we have now, because of the…they have some abrasive in them. Aluminum oxide I think it is. You’d have to almost become an over aggressive brusher to do damage to your teeth rather than help your teeth. Now I did have some patients who did brush the notches into their teeth. They’ll cut a notch into their tooth and I’ll have to put filling into that notch. But that’s a complex process. It’s starts from a notch. You take teeth out instead on a block of plaster and you put a tooth brush on them. And you mechanically brush that. You can’t get a notch form like it forms in the mouth. It just doesn’t happen. You don’t get the notch. But in the mouth there’s occlusal forces on the tooth and you’re taking a crystalline structure and compressing and flexing it. So that crystalline structure flexes and it’s going to flex at the weakest point, the neck of the tooth. So that crystal structure starts to chip out and it gets a little bit of a depth. Bristles want to naturally fall into the depth of the notch and they start forming a deeper notch now and just keep cutting it deeper and deeper. Then I come along and then I kind of do some body and fender work and fill that notch in with tooth colored composite. Not because there is decay there but I just want to keep the toothbrush bristles out of the notch. Cause I don’t want patients to amputate their tooth.

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