I love coming into work and seeing a new patient on my schedule. I get all giddy inside and am full of anticipation. What will I find? What can I teach them? How can I make them healthier?
This week I met a wonderful middle aged gentleman for the first time at my office. He was excited to be seen in a dental office as it had been about 2 years since his last dental visit. He had left his last office because he felt something wasn’t right. His intuition was correct.
A full set of xrays revealed overfilled root canals, open contacts between teeth, recurrent decay under old overhanging amalgam margins, moderate bone loss and subgingival calculus that you could hang a coat off of. My heart sunk. This man trusted his dentist to serve him ethically and skillfully. Unfortunately this was not the case.
This made me wonder how patients choose their dentist and how they should.
This is how patients currently pick their dentist:
(1) Cost – Most patients refer to their dental benefit package to choose their dentist. They will choose their dentist based on their coverage and their out of pocket expenses.
(2) Location – Office right around the corner? Great. Offices that are close to work or home are ideal for new patients looking for a dental home.
(3) Convenient Appointment Times – Some offices start early (6:30 am) and some stay open late (9:00 pm). This helps the working patient who has a job and the finances to pay for dentistry to come in to have work done.
All of the above are great reasons to pick a dentist, but there is more. We should be helping our friends and neighbors understand what questions to ask when interviewing their next dentist.
I recently posed a question to dental hygienists on an online social media forum asking then how they would tell someone to find a dentist if they moved to a new location. Some said to ask a local periodontist or endodontist who they would recommend. I have offered this suggestion to my patients but I wonder if it is the best way. Specialists enlist referrals from general dentists for their business. This may be a conflict of interest when asking for a recommendation.
Could you ask friends? What are their reasons for suggesting a dental professional? Are they gentle or nice? Is there a better way?
Let’s come up with questions to ask.
(1) How long are your checkup appointments?
· Does your hygienist probe at every visit?
· Do you perform oral cancers screenings at every visit? Do you have advanced equipment to examine the oral cavity?
(2) Do you have a remineralization program? This will help determine if the practice is a drill and fill practice or more focused on prevention.
(3) How do you calm patient’s fear? Can a patient stop a procedure and feel in control while it is going on? Do they offer sedation?
(4) How do you handle finances for large cases? Some patients like to get everything done at once and need to know financing options.
(5) What are the Dr and RDHs favorite CE courses? This will get a feel for their passions.
(6) How long has staff been in practice in this office? Dedicated employees create value of services in a practice.
I’m sure there are many more questions we can come up with to find the perfect office with quality services. Patients rely on us to provide quality care at reasonable prices in the least amount of time.
I hope next week at my new patients treatment consultation appointment he realizes that he has chosen the right office with the ability to give him his healthy smile back. My anticipation mounts!
The Power of Spit
When you think of spit most people will think of the verb “to spit”. You can spit to show emotion, to lubricate things on a whim or, for little boys, to gross out their little sisters. We know that spit is actually more important than that.
Saliva is useful for digestion and lubrication of oral tissues. It is full of information about bacteria levels and even provides DNA for research and criminal investigations. Saliva also has the ability to remineralize and demineralize teeth.
Dental decay still runs rampant in our society. Many blame heredity and the inherited “soft teeth” from their parents. I have come across patients, that for years, have been told more brushing and flossing will stop their decay yet the decay continues.
Approximately 2 years ago, I introduced pH testing in my clinical setting on all patients coming in for their preventive appointments. Surprisingly, only a small number of patients were willing to be educated on how a low pH (high acid) saliva affects their teeth. The cost of prevention deterred them from completing a xylitol regimen to increase the pH and starve out the Strep mutans bacteria, the major (but not the only) culprit of the perpetuation of decay. Since xylitol is considered a food (sugar) it cannot be prescribed to our patients like antibiotics can. Food is not covered by a prescription health plan.
Since healthy saliva is the key to stopping the spread of dental decay education is the only way to get the key to the door. Education of patients, and their parents, about the frequency of food/drink ingestion to decrease the amount of acid attacks and the types of food which increase the pH into the neutral zone is needed as well as the introduction of xylitol, if they decide that they want to be more proactive in busting cavities.
During dental exams we examine teeth and gums. How many of us are examining saliva? Clinicians are responsible for education about the whole mouth and everything in it. Spit is important.
DDD and the RDH
What is Degenerative Disc Disease?
Degenerative disc disease is not a disease per se. It is a condition to describe chronic pain caused by a disc in the spine or neck. Typical person with DDD is a healthy active person in his/her 30’s or 40’s.
What Do Discs Do?
The discs of the spine are designed to make the back and neck flexible. These discs are shock absorbers made of 2 layers that help with this flexibility. The annulus fibrosus is the outer fibrous band layer. The nucleus pulposus is the innermost layer and can be described as jelly like.
If the inner disc material comes out of its enclosed area due to damage to the annulus fibrosus it may come in contact with the nerve root extending from the spinal cord and create pain. This pain may radiate to the leg causing what is called sciatica or lumbar radiculopathy or down the arm causing cervical radiculopathy. Once a disc is damaged it cannot repair itself due to its limited blood supply.
The body, sensing less stability in the spine due to disc herniation, tries to create more stability by adding bone to the spine. These bony spurs or osteophytes can potentially impinge on the nerve roots extending from the spinal cord and cause pain.
Symptoms of DDD
The first sign of a problem with the neck or spine is stiffness. One may notice periods of severe pain that comes and goes. The pain may be felt when seated and worsening when bending and twisting. Numbness or tingling in arms and fingers and weakness in extremities caused by damage to nerve roots extending from the spine and should not be ignored as nerve damage can occur. It has been found that some alleviation of some pain symptoms may occur when walking or changing positions.
Causes and Risk Factors of DDD
There is no one reason degenerative disc disease occurs. The drying out of discs decreasing the height of the space between vertebrae is a factor as is injury. The injury that occurs could be an acute trauma, such as a car accident, or chronic trauma, such as high repetitive tasks that occur over years.
This is where the practice of dental hygiene would be considered a risk factor for disc problems. The act of providing dental hygiene services to patients is a highly repetitive act. Many hygienists favor keeping their patients comfortable rather than worrying about the effects of their posture on their health. A slight change in head tilt, just a mere 15 degrees adds 27 pounds to the head!
Since there is radiating pain from the spine the source of the pain may not be brought to physicians first. Shoulder pain may not be shoulder pain at all. The pain may be radiating from the neck. All symptoms must be accounted to physicians including pain, numbness, tingling.
Magnetic resonance imaging (MRI scan) can help to determine damage to discs and a neurologist may perform a nerve conduction study to determine nerve damage of numbness and tingling are symptoms.
Conservative therapies such as physical therapy can be helpful as well as exercise. Alternating 30 min strengthening with low impact aerobic exercise such as walking, biking or swimming can keep the areas limber and make muscles of the back and shoulders stronger this must include stretching.
Proper body mechanics and keeping hydrated will help decrease the chance of a flare up as well. Twisting and bending from the back could cause more pain. Using arms to help raise the body from a seated position as well as using larger muscle groups such as quadriceps for bending instead of bending from the hips/back are ways to use proper ergonomics.
When the pain is severe doctors may prescribe anti-inflammatories and steroids as well as heat/cold compresses. Epidurals can be used to diminish the inflammation as well, although only work about 50% of the time.
Surgical intervention such as a fusion or a cervical disc replacement may be necessary if all conservative therapies have been tried with limited success. From personal experience, this may be an option that alleviates the pain you have had for years.
What is an RDH to do?
You are the most valuable tool of your career! You need maintenance just as your instruments do. Spending money on loupes and an ergonomically designed chair is only the beginning.
Be self-aware. What you do everyday will impact your life. Do you feel a twinge somewhere? Investigate. You may be positioning yourself, or your patient, incorrectly. Sit, stand and change positions frequently. Take a walk. Drink water.
Degenerative disc disease may not be preventable but managing is possible with the right information and a great medical team.
October is the month in which the dental hygienists are celebrated for their nagging efforts to make their patients healthier. After almost 2 decades in dentistry I’ve learned that my patients don’t care about cavities or whether or not they have gum disease. I’ve talked and, yes, actually nagged my patients for years to brush better or floss more or they would have to suffer through listening to the same recorded message again at the next appointment. I am done fighting with patients who don’t want to listen to me anymore. I am giving up because I care.
To celebrate National Dental Hygiene Month I’m changing the relationship I have with my current patients and the relationships I will have with my future ones, by making some promises that I plan to keep. (1) I promise to tell you what’s important to you, not to me (2) I will only teach you to avoid dental diseases like cavities and gum disease if you want to learn how (Psst, here’s a secret, all dental disease is preventable and learning how to prevent it can save you thousands of dollars!) and (3) I will always tell them if their breath smells worse than a sewer…because I care.
The reason I am making these promises is because I’m tired of butting heads with my patients and them not getting healthier. Our goals have always been different. My goal is to tell patients that they could have a life threatening illness and a decreased quality of life due to a bacterial infection of the gums called periodontal disease and get them to treat it. Most patients don’t care if their gums bleed because of this infection, even if they should be running to the nearest dental office if they do.
What is their goal? Their goal is to get out of the office without me saying the dreaded “F” word. If they have to hear the word floss one more time they’re going to lunge at me and strangle me with their bib clips and watch my face turn blue. I can see it in their eyes!
For years, I’ve given them information they don’t want to hear. I know bleeding gums mean an infection has already invited its way in and is causing inflammation in their arteries making them sicker every day. I know that it contributes to high blood pressure, heart attacks strokes, the inability to maintain good blood sugar levels and that it even could cause premature babies. Unfortunately, they only hear this message in one place…their dental office.
Most medical doctors have too much on their plates to discuss oral health with their patients. Unfortunately, we are not collaborating with medical offices to educate patients about the oral systemic link. Since we in the dental offices are the only ones talking about how bleeding gums are bad I’m going to stop sounding like a crazy person trying to get patients to understand the complicated scientific facts of oral health.
I will focus on the affect of the bleeding gums on their everyday lives. Family and friends won’t tell them that their breath smells like a landfill in the middle of a summer full of 100 degree days. So it’s actually my job to tell them that the bacterial infection that causes bleeding is making their gums rot creating decomposing corpse breath. (Yes, cadaverine is a smell caused by bacteria). For years I tiptoed around this fact and instead told them a complicated message they didn’t care about. For that, I am sorry.
If you were to visit me for your dental hygiene visit what would our new goal be? Do you want whiter and straighter teeth? Would you want to learn how to stop paying money to have cavities fixed? Do you not want to have to wear dentures like your parents did? Your goal is now mine. I will tell you what I see, feel and smell because you deserve that. I am here to get you healthier but only when you want to. Until then, I’ll be waiting.