Covid-19 and the Dental Office

1. What should I look for in the first ten minutes at a dental office? 

    • Cues on hygiene

Is the place clean? Make sure you use the toilet. If the place is not immaculate, nor will the instruments be. There are not two standards.

    • Is the Team detail-oriented? 

 Look at decoration, not too sober, nor too eccentric. The personality of the Dentist comes through those minor details: uniforms, the overall presentation of the Team. 

    • Look at other Patients in the waiting room. It is not so much about profiling or judging on looks, because a patient-base does not have to be all that homogeneous, but a Doctor that has been practicing for over ten years has Patients that reflect unique aspects of her/his personality. 
    • How is the Team? Your first contact with the receptionist or whoever greeted you? Maybe a simple question about parking can help you. How every member of a Team is chosen by the management says a lot, so try to evaluate them too. 
    • Did you feel environmental stress, or did the place invite you to relaxation? 
    • Did one of his staff take you in the dental room – also called an “op”-? Did it take the Dentist thirty minutes to join? If so, how was that handled by the Team?  Were they too busy running all over the place, or did they show calmness and attention? Did you feel they were available to meet your needs?
    • When you walked in the op to meet the Doctor, did you like the body language? Did they smile? How were you greeted? Was the doctor scrolling the mobile screen? 

Based on your answers to the above, conclusions can help you already decide if that’s where you want to be, depending on what you are looking for. 

2. Is there a reason during treatment we go to the Dentist every week? Can this be different? 

There is absolutely no reason for appointments to be weekly. In fact, I have never done this. Some treatments will require a healing process to happen, and that can be anywhere between one week and even six months, depending on the procedure. 

Sometimes, if there is dental lab work, which enters the category of dental prosthesis, based on the job requested and the lab, it can range from a few days to two weeks. 

I have often worked with Patients that lived abroad and just came to get a treatment done or something fixed. We would set those Patients up for rather lengthy appointments, and the frequency would be high, based on the duration of their stay. Also, if you must commute interminable distances to go to your Dentist, you can request they do as much as possible in each appointment. This has always been my preferred choice. There is less risk of having a Patient get de-motivated halfway through treatment if it lasts three months than if it lasts eight months. 

A Dentist that sees eight Patients or fewer in a day will be less stressed and much more available to meet unpredicted situations, which believe me, will arise. One that sees eighteen patients in the morning and seventeen in the afternoon is irritated by 2 PM because of dehydration, and the Team is so proud of their lack of availability that they might even share it with you:” Sorry Jane, the Doctor cannot see you on Monday we already has seventeen patients”. If this is the case, say you will call for an appointment and get out. Busy is good, overbooking is not. Also, a discrete Team is a must. Stress will exacerbate the neurotic behavior, and that cannot be good. 

3. In my country, there are specialties in dentistry. When should I go to see a Specialist? 

The decision to see a specialist is preferably your general Dentist’s, not yours- we call him/her a GP, General Practitioner-. Let’s make the Specialist a “he” and the GP a “she” for ease of speech. The specialist may have his own practice or could be a member of the same Team as your GP. It is challenging for a specialist, no matter how good he is, to have a global view of a treatment plan. Specialties are good because they make the professional more skilled at what he does. Also, by limiting their field of work, they rapidly gain more experience, thus expertise. But their focus will be on the treatment they are doing. A well-trained GP will have a view of the journey and the goal and will coordinate better a multidisciplinary case. 

When a GP delegates segments of the treatment to a specialist, you want her to be a control freak. 

What I think works best is a multidisciplinary Team under one roof. I am a professional control freak, and that gave me a better oversight.  

4. How long can I expect a successful dental treatment to last?

That’s a tough question to answer. One thing is sure, do not stay in a practice that gives you a life-time warranty unless they are in the center of a roundabout where four highways meet and have no parking. Lifetime warranty in medical is beyond dishonest and unethical. 

The first thing you must remember is that success is dependent during and after treatment on both the Dentist and the Patient. Responsibility is, in my opinion, 50-50. I am not trying to get away with murder here. Just bear with me for a second:

    • Hygiene is fundamental. If you have had had poor hygiene for forty years, and “suddenly” spend a fair amount getting your teeth fixed, it will take top-level discipline and will, to behave differently. Many of you will not. A tooth that has a crown has a higher risk of having a decay than a natural tooth. So does a tooth with a filling. Thus, if brushing is not enhanced after treatment, nothing will last, no matter who does it, no matter how much you paid. 
    • Please use an electric toothbrush. I can’t believe you can buy an iPhone XL56 with 3TB of ram and brush your teeth with a manual tooth-broom even if it has 150 bristles. Also, please floss unless your brushing -electrical- is immaculate. 

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5. I have had many root canal treatments fail. Isn’t it better to extract the tooth and place an implant? 

Another tough one. Root canal treatments, classified under the specialty of endodontics, are possibly the most sophisticated treatments aside from some surgical procedures. They require a level of precision and expertise indescribable to someone that is not a professional. Two complications can arise from a failing root canal:

a. The root canal looks perfect on an x-ray, and yet, one, two, three years later, it gets infected. The anatomy inside a tooth can be very sneaky; there can be additional nerves, lateral micro tunnels, and whatnot. If all is not entirely well sealed, bacteria will develop. 

b. When we do a root canal, we are removing all source of life from the tooth, thus hydration. The tooth becomes brittle, cracks, and the risk of fracture grows exponentially. It will have to get a crown as soon as possible, but even in that case, a fracture might happen, and the tooth may require an extraction. 

In the first case, endodontists that work with a microscope and using 3D radiology to check on the result, have a better chance at succeeding. You will pay an arm and a leg for that root canal. Some skilled specialists have top rates of success despite not having such sophisticated equipment, but again, they will be as expensive because of their experience. 

In the second case, for all you know the treatment might have been done by the super-mega specialist from option (a) but this might not stop the tooth from fracturing.

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6. What about periodontal disease or bone disease? Why does this happen, and what can I do? 

Periodontal disease is a problem that affects the periodontium, which is how we define the tissues around the tooth. Surprisingly enough, we know little on why it happens, as we haven’t been able to link it to a specific gene. We know it is congenital, meaning transmitted from father or mother to child. We know it is caused by bacteria. It can be aggressive, rapidly evolving. It ultimately causes teeth loss because of the destruction of the supporting bone. The only factor the patient can control is bacteria. Hygiene in a periodontal patient must be extreme. Become obsessive-compulsive with your dental habits if you wish to preserve your oral health and spend your funds on a house rather than your mouth. All of you need to do regular check-ups with the right Dentist so that, if you are a periodontal Patient, you get an early diagnosis and change your behavior before it is too late. Untreated, periodontal Patients will lose multiple teeth, require implants, and often grafting techniques to replace the lost bone. Caught early, it can be surgically treated and will require dental bridgework. Not that many Dentists are well trained to do periodontal surgery combined with periodontal prosthetics. You may need to search and visit over one to find the pearl. 

When it remains untreated, periodontal disease increases the risk of endocarditis, which is an infection of the tissue that surrounds the heart, because of bacteria migration through the bloodstream. Endocarditis is often deadly, so once again, don’t underestimate the risks. 

7. My husband says that either I am in love with the woman Dentist that fixed my teeth, or I have Stockholm Syndrome. Can that be? 

Both can be! The Dentist works awfully close to her patients. The recurrent physical contact, added to the fact that we try to make our moves soft and caring, can induce certain feelings, often platonic. The fact that you are a woman, and so is she, does not make it impossible I am sure you know that!

As for the Stockholm Syndrome, 100% yes. In 1973, an escaped convict entered a bank in Stockholm, pulled a gun, and yelled: “The party has just begun!”. He kept four people, hostage, for over 130 hours. He developed with them bonds that became historical. Not one hostage spoke severely of him. When he surrendered, the police asked the hostages to come out first, and they refused. They came out with him to prevent the police from shooting him. That relationship is called the Stockholm Syndrome. 

I can only wish you all to feel that way once your treatment is over. It will mean you chose well, and you developed the right bond with your Dentist. 

8. Are dental implants the panacea? Can they fail? 

The panacea, if there is one, is keeping your teeth. Nothing will be as perfect as them, nor as well-engineered. Once you lose them, then dental implants become an option. There is no medical solution for anything better than what you had initially. A dental implant is made of titanium, so yes, one enormous advantage is the fact that it does not decay. Aside from that, it can develop bone disease, and it is difficult to control and treat. Implants must be checked more closely than teeth with x-rays. The moment there is a problem, treatment must be immediate as the device doesn’t have a defense mechanism. If we do not check implants regularly and they fail, they can create an extensive bone loss that may very well prevent their replacement. An implant that is failing might not cause discomfort in the first stages, thus the need for regular check-ups. 

Implants indeed have the second-highest success rate, to extractions. Extractions have a 100% success rate -you get it right

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9. I am upset with my Dentist. How should I deal with it?

Your Dentist is a human being first and a professional second. Have a discussion, talk. I cannot approve of the low consciousness US-based habit of suing medical professionals, most often motivated by greed. If you believe we have done something wrong, talk openly. We are not machines and can make mistakes. If you think it is a case of malpractice or can’t find a way to have a proper conversation, contact your local board of Dentists and discuss it with them. They will help you evaluate your case and will mediate with the Dentist. By suing inconsiderately, you are only helping lawyers. It will do nothing for the betterment of our profession or future patients. That’s the role of the Board of Dentists, to regulate how we practice and sanction when required. Often, another Dentist will start criticizing what has been done in your mouth by a colleague. That’s a reason to leave that dentist. An unethical professional will be immoral at all levels. Competent professionals don’t talk badly about other people’s work because they know we all can fail. I wish I could reverse this pattern, and raise the level of consciousness of the profession, but also of many patients who seem to be waiting for a well-intentioned Doctor to slip to jump on them like a starved lion. How can anyone practice fully and well in such circumstances? After all, it is a way of creating fear the other way around. 

If you want to help create a better world there too, between Dentists and their Patients, don’t listen to lawyers and even less to other dentists, that push you to sue a colleague. Lawyers get a cut of what you get. That’s all. Really? That’s how low we’ve come? Have you ever heard about karma? Make peace, not war.

 

10. I know smoking is terrible, but I am addicted to it. I can’t imagine the stress of getting my teeth fixed and quitting smoking all at once. 

My first answer will be a rhetorical question: Where do you think the effects of smoking are felt first? You’ve got it! In your mouth! It is the first filter, but it gets worse. Do you know that when you take a puff, the temperature is- raised to fifty Celsius–-one hundred and twenty-two Fahrenheit- inside the mouth? What that does, when you know that the ideal temperature for our cells is thirty-seven degrees is not good. You can try to be smart and say that drinking hot tea is thus no better. But you are not inhaling the tea with the agonizing desperation smokers have as if that puff was the last one, they will ever take! So there goes the smoke with all 7,357 chemicals in it at the speed of a Ferrari, and with the pressure of a tennis ball against your teeth, gums, palate, and cheeks. Right. Maybe you can enjoy it with a gin and tonic!

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11. As far as I can remember, I have seen my parents wear dentures, and they were happy. Why shouldn’t I just go for that if I don’t mind having something removable? 

Now that is an excellent question. Dentures look good. They look better than any other prosthesis our Lab Techs can build because everything is artificial in them, the gum and the teeth. They can look very natural; in which case it is hard to know you are wearing a denture. There are downsides to them, and those will increase the younger you are since you will need more years from them. 

    • A denture will wear your bone down. The bone of the jaw is right under the gums and gives support to your full dentures. As you wear these, the bone will be resorbed, and comfort will be reduced as the years go by. The denture will lose stability and will start moving. It will be even more noticeable with the lower one, because of the lack of palate, which reduces, even more, the support. 

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12. Many years ago I have been given a treatment for osteoporosis which I am still taking. I had implants and they all failed. I was told it was due to my condition. Is that true?

Wow. NO. 

Let me start saying a few words on osteoporosis. There is no proven relationship between general osteoporosis and osteoporosis in the jaw bones, upper or lower -maxilla or mandible-. As I mentioned in a previous answer, what stimulates bone, is activity. There is something called Wolff’s law. It states that bone in a healthy person will remodel itself to become stronger to resist the load. In the same way, as you chew, your jawbones are stimulated continuously to withstand the load unless teeth are extracted. Whether you are twenty-five or eighty-five, man or woman, you will lose bone density and volume if a tooth is pulled out. 

No matter the age, the resulting bone is not the same structurally in the upper or the lower jaws, in the front area or the back and as surgeons, we handle them very differently when we work.

As for global osteoporosis, personally, and I am only a Dentist, from all my readings, I am a firm believer that it comes from our bodies being excessively acid, and the genius behind our creation having set up the right mechanism to grab minerals wherever available to bring the balance back, thus depleting our bones. If we take the problem at the “why” level rather than just medicating us, we modify our food intake making our body more alkaline, exercise, stop smoking, we can reduce the problem considerably. 

Now on Bisphosphonates, which is the category of medication you were given. Let me make here a few more friends, LoL. The pharmaceutical lab Bayer created a precedent by discovering the applications Aspirin® could have as a blood thinner for patients with some cardiovascular conditions. The drug, as you know, was initially only intended as an analgesic and anti-inflammatory. This was genius, nothing to say. Alas, it served to prove to the pharmaceutical industry that instead of investing trillions in research and development, if they could find other applications for pre-existing drugs, they could also hit the jackpot, and it became almost a  derived business model. 

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13. What is the ideal maintenance with or without dental restorations? 

As I tried to emphasize at some point earlier, using an electrical brush is my opinion the way to go. The heads must be replaced every two months approximately. I am not a fan of oral irrigators unless you are sure not to reduce the brushing time by using this extra tool. An irrigator will give a sensation of cleanliness that ends up making most patients believe it is as good, and it isn’t. Nothing can replace the efficiency of a brush. I will say the same for interdental brushes. They are the ones that fit transversally into the spaces between teeth close to the gum. They are indispensable for periodontal patients or people above forty-five due to the bone loss we’ve naturally suffered – yeah… I am there too, way above-. As we lose bone, which is a physiological process, small triangles appear between teeth and/or restorations and they need to be very well maintained. In my opinion, flossing vs. interdental is a no brainer; the latter wins all the way. 

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