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Broken Down Cars and Good Teeth

This morning I had an automobile breakdown in my “beater” weekend truck. We have all been there-- filled with the inconvenience and anxiety of dealing with a problem that came up unexpectedly. I was appreciative to find a place that could get me home that day. I googled around until I found a reasonable looking repair shop close to the breakdown. They worked me in to their schedule so I could get the old truck back on the road. It was pleasing to have the problem fixed, at least for that day, but I measured this against how I have experienced service at the shop that takes care of my daily driver car.

There were many things about the breakdown with my old pickup truck that reminded me of a dental emergency. I found someone that I could trust and they had the best intentions to provide a fix. It was a shop that I didn’t have a relationship with. They were kind and helpful, but there were so many things missing that would have been unlikely to happen if I treated my old truck like I do the car that I have been so much more diligent in taking care of. The shop focused on the problem that was presented to them, not looking beyond a simple fix to get me back on the road. While I was appreciative, it is very unlikely that the next problem (or even the cause of this one) was looked for. I did not leave with any feeling that I would not be in a similar situation as soon as the next problem arose.

I reflect to the years I have spent with the auto shop that takes care of my car. I have a valued relationship with them. They know me and know that I appreciate them taking the best care of the investment I have in the vehicle I drive everyday. When I take my car to an appointment, they look over everything and tell me when to expect maintenance and repairs in the near future and through the life of the vehicle. I trust them and know that they have have the best interest for me and in return I am very appreciative, expressing gratitude when I write them a check for their services. I have never “broken down” in the cars they take care of for me.

 

Coincidently, many days, I use the analogy of cars to taking care of teeth with my patients. We wear away the surfaces of our teeth similarly to how tires age. We pay for maintenance and parts with an equal financial obligation. When we have to start over and restore our vehicle (or get a new one), sometimes it costs the same as major treatment we could have done for our teeth. Sometimes the auto investment is inconvenient and causes urgency. Often, if we chose, it is predictable and pleases us. We find ways to pay for it. Individuals always seem to find ways to pay for the things they value. We chose our own experiences. I invite my patient family to consider experiencing dental care in my practice similar to the good experience I have had with reliable and well maintained cars.

 

The business card for my practice has three tag words on it: Restorative, Comprehensive, and Esthetic. I have been told that these are three descriptors that have a very obscure meaning for new patients to understand. Why not be like the dentist down the street and just say “Cosmetic” or “Family Dentistry”? I believe every opportunity I have to explain each of these focused goals for our patient care enriches the dentistry I am able to provide patients. So many in our patient family have learned through these experiences exactly what these words mean.

Comprehensive: Simply that we look at the patient as a whole. We observe and diagnose globally and intend to partner with our patients in a thorough individualized manner. The best dentistry does not happen when we just look at a tooth with a problem, in fact it isn’t much better when a dentist has a look at your “teeth”. Comprehensive Dentistry considers the whole system and the individual. How are the muscles and joints that affect and are effected by the teeth and their use considered? How are the structures that support the teeth? What are the factors unique to a patient’s habits, routines, and systemic health that relate to ideal dental health? What are a patient’s individual goals, desires, and expectations? Will the dentist take everything they can gather about the causes of problems and consider them in the solutions? The list goes on. This is a highly intentional paradigm of patient care .

Restorative: The focus on restorative dentistry is just as it sounds. In our practice, we want to restore patients to an ideal state of health and function. Tremendous effort toward continual education, technology, and our approach to care beyond the average dental setting has been placed to achieve this ability.

Esthetic: Esthetic Dentistry speaks to taking great care in the art and science of making dentistry beautiful. Yes, it is a nose thumbing at the overused term “Cosmetic Dentistry”. We believe that all good dental restoration is more beautiful if provided in the context of health and function. At the end of a good day, we want to create smiles that our patients can be proud of because they are beautiful, healthy, and durable.

 

We all have things that we value enough to invest in. We all make choices that take effort because we want the result, just like my car that I enjoy and that is reliable. I invite you to consider that experience with your teeth through the comprehensive approach.

Behold: Perfect Teeth

 

Perfect teeth

I see lots of teeth. One at a time in a normal month, I’d say I individually peer over 100,000 to maybe 120,000 of them. Occasionally, definitely not everyday, I see what I might consider a perfect compliment of them. Yes, that perfect smile of healthy teeth and gums. It’s a rare thing to behold (even in a dental practice), absolutely far more rare in the general population. So when I see those perfect pearly whites, I am not hesitant to offer a compliment. I’ve even been know to photograph them for reference. A thought crossed my mind a bit back that I should start looking for a pattern. Why are these people so blessed? I was not surprised that the thing all of these folks had in common was a simple set of habits. These habits and attitudes are rather intuitive-- but living with them seems rare, shared by owners of teeth that prove these pearly whites are loved. Part of me wanted to post this list on a sign, maybe a cross-stitched pillow or something in my reception area, but better judgement gets the best of me every time-- so here is this blog.

 

The top 9 ways I’ve observed to maintain perfect teeth and oral health.

 

  1. Do not smoke. Seems Logical-- but tobacco has a very ill effect in the mouth causing staining, malodor, gingivitis, and periodontal disease, and even cavities through drying the mouth.
  2. Floss. Over 1/3 of thesurface area of teeth is untouched with brushing alone. It is extremely rare to see perfectly healthy gums in people that do not floss properly and regularly. Healthy gums are just as important as white teeth in a healthy smile. Pink, stippled like an orange peel, firm, and sharp between the teeth-- this can be maintained by anyone willing to put forth the effort. Sadly most people do not floss regularly.
  3. Brush with intention. Most folks brush their teeth, but how, when, and why plays a huge factor in folks that have perfect teeth. Perfect teeth people are passionate about technique rather than just scrubbing because it is bedtime or they just woke up. They brush after exposure to sugar- even carbohydrates like bread, in fact, they often brush after almost any food consumption. They are gentle and deliberate, in fact, some folks harm their teeth, root surfaces, and gums scrubbing to just get it done.
  4. Don’t fall for gimmicks. There is no holistic remedy, mouthwash, or breath mint that takes the place of regular good flossing and diligent brushing with fluoride toothpaste.
  5. They don’t drink beverages with sugar in them. Most of them would tell you that water is their favorite drink. Sugar drinks is the biggest cause of problems, acidic drinks are often a culprit in enamel loss (coffee, tea, soda, juice). Gatorade is a soft drink not a health supplement!
  6. They use their teeth for smiling and eating-- not as tools. They would never open a package with their teeth, bite at a nail, or nip fishing line with their choppers.
  7. They value their teeth greatly. After reading the above this may seem very self evident, but they see oral health as a must and pursue it with fervor.
  8. They value health greatly. Most often it is evident that the attitude toward health is not exclusive to the teeth. Factors like diet and willingness to put in the effort for oral health is very intentional. If you ponder on it, the same things that lead to diabetes and obesity aren’t good for teeth. Not to mention good oral health has implications on systemic health, specifically oral inflammation with gingivitis and periodontal disease. Did I mention the importance of flossing?
  9. They take a pride and ownership in their high level of health. Usually folks with healthy teeth know it. If something goes wrong, it is most likely something they can not control like a bite issue or an accident, but they are eager to consider correcting it.

 

 

Yes, this seems picky and even daunting! No wonder finding a smile full of perfect teeth is rare, perhaps less than 1% of the population! Blessed are those that don’t have “sins of their youth” (cavities, etc. from childhood) or previous dentistry to maintain (which takes even more effort)-- but I see plenty of folks who pick up these habits and attitudes that have not had them their whole life and they are (with a little help from a good dentist), indeed perfect. The practice of dentistry is a paradox. We dentists might be seen as folks that make our living “fixing” all the problems that arise, but at the same time we are highly motivated to encourage prevention and play defense against disease. Why? Because health is beautiful and exciting. Also, in a perfect dental practice, we would be working in a healthy m

outh solving the riddle of restoring back the factors that people can not control. We find when these owners of a perfect healthy mouth rarely need our care, it is met with their welcome and our achieving great outcomes together is easy.

Value of Continuing Education

Tanner Study ClubI want to share a story about learning.

Eleven years ago, immediately after graduating from dental school I did what every dentist does-- because they have to-- and joined up in the local dental society. I went to the North Carolina dental meeting and sat through the continuing education lectures. After each slideshow, each lecture I found myself walking away with a "pearl" or two of useful information. It was nice to learn about a new material (the lectures in these venues are usually sponsored by manufactures) or perhaps a glimmer about something bigger that your average Dr. Joe could do more of in the dental practice, but I knew more was out there!

A bit disenchanted, I began to look to accomplished mentors and dentists that I admired to help define how the care and services in my practice could be improved. What I learned was that there was a whole world out there of very talented dentists that where dedicated to a lifetime of continued learning. Then in that first year of dental practice, a blessing crossed my path. Our local periodontist, Dr. Ron Nason, invited me to come with him and several other young dentists to the L.D. Pankey Institute in Key Biscayne, Florida. Little did I know that on that trip I would foster some of my greatest friendships and collegial relationships and begin a journey in dentistry that defines my attitude toward delivering dental care. After a week of intensive study in Florida, my eyes were opened. The elements of a completely different paradigm of dentistry (and life) were laid out before me.

In the years that followed, and now still, I find myself spending many days a year learning (and now teaching) comprehensive dentistry. While the state dental board requires 16 hours of continuing education a year, it is not uncommon for me and my dental team to amass well over 150 hours. As I worked my way through the continuum at Pankey, I developed a relationship with my mentor, Dr. Todd Davis, who practices in Atlanta. Since 2005, I have returned twice a year to a study club held in Todd's Buckhead restorative practice facilitated byTodd's mentor and renowned master dentist, Dr. Richard Green. As the years past, Todd started traveling up to Gastonia a couple of times a year-- on each of these trips he keeps me and my team on our toes and accountable for the learning goals I set with he and Dr. Green in our bi-annual weekend meetings.

In addition to learning at Pankey I have invested time learning restorative dentistry through Spear Education in Scottsdale, Arizona. Dr. Frank Spear is considered, perhaps on a the world leaders in dentistry. At home with several close colleagues, I facilitate and participate in a monthly local study club that reviews advanced restorative cases packaged by Spear. I have found that the technical excellence taught by Spear's team, the comprehensive-behavioral philosophy of the Pankey Institute, and my experience in the Atlanta Study Club ground the basis for my practice philosophy.

In addition to my journey with these more comprehensive focused programs, I still participate in technical and procedure based learning. Our practice has provided CEREC ceramic restorations since 2005. By combining the ethics and comprehensive approach of Spear and Pankey to learning this technology, we have become leaders in providing excellent same day, office manufactured restorations. With Dr. Nason, I have also spend three years of extensive study in the Biomet 3i Synergy Implant learning program. From this, my practice has teamed with Dr. Nason to provide our community world class services in predictable dental implant procedures.

I am still involved in the local and state dental societies, I find that they are the backbone that makes dentistry in our community such a pleasant environment to practice in. I now take the learning from my wider journey toward mastering our art and view all the events that present learning in dentistry as opportunities to learn and teach others.

I can say that if a dentist ever finds themselves stagnant, our profession always has a world out there to learn from and master.

And so I say thank you to those that teach, inspire and mentor me . . .

Dr. Bill Kelly, a father who always is patient and full of wisdom; Dr. Richard Green, a mentor and teacher that continues to inspire generations in our profession; Dr. Todd Davis, the mentor that pushes me in a vulnerable learning environment; Sheri Kay, RDH, who gives me energy and inspiration; Dr. Ron Nason, who has a vision for better dentistry in our community; Dr. Will Current, my learning and accountability partner; to all of my colleagues and friends in the Pankey, Spear, and ACT Dental community nationwide that provide support and inspiration; and importantly to my loving family that kindly yields their time with me for my pursuit of learning.

Dental Implants vs. Bridges: Pros and Cons

Unfortunately, for a variety of reasons, the condition of a tooth sometimes deems it necessary to remove it. In the past, the choices for replacing a single tooth were: not replacing the tooth, fabricating some type of removable appliance (like a partial denture), or making a fixed bridge (a crown on either side with a false one in the space). Today it is rare for a patient to desire going without or a removable denture, so we are left with two choices: a fixed bridge or placing a dental implant with a crown over it. Both options are very desirable and have great outcomes when indicated. Both options are typically a major investment that patients must be willing to make to restore health, beauty, and function. They are usually both treatments that patients with dental plans can receive some assistance with, but typically require some personal investment beyond insurance (of course, we think it is worth it to support health and happiness through the patient's life time.) Not replacing teeth with stable restorations can result in teeth shifting causing negative effects on other teeth, not to mention the benefits to chewing efficiency and appearance.

Bridges

The option of a bridge has been around in dentistry for a long time. It requires that there are two or more healthy, restorable teeth on either side to support it. A bridge can be a very beautiful and predictable option for replacing missing teeth in many cases and is still viable for us to consider with patients. Traditionally, bridges were made with metal based dentistry, either all gold or an alloy core with ceramic layered over it. Today, in most cases (in my practice nearly all cases in which we chose a bridge) bridges are now made with strong, durable, and more attractive all-ceramic materials.

Bridge Pros:

Can be accomplished over a short span of time in 2-3 appointments.

Replaces missing teeth attractively.

Usually allows gums around restored teeth to look natural.

Cost is usually around 75% of the cost of a single implant.

Could be beneficial if neighboring teeth need crowns anyway.

Bridge Cons:

Over treatment of neighboring teeth if not needed on them.

Long term prognosis 20+ years lower than implants, lower if the supporting teeth have already had very extensive dentistry.

Teeth are connected, therefore if one has a problem in future they all do.

Must floss under bridge rather than through tooth contacts.

 

Implants

Single tooth implants have been around for decades, since the turn of the 21st century they are very common and becoming considered the standard of care in most situations where a single tooth is lost. An implant is placed precisely by a surgeon after an evaluation and consultation. In some instances it can be immediately restored, in most cases the implant that is integrating into the jaw bone must heal for 3-6 months before it can be restored. When the implant is ready for restoration, Dr. Kelly designs an abutment (a part that attaches to the top of the implant just under the gum line) and a ceramic crown to go over it. Single tooth implants, when well planned, are very predictable and have an excellent long term prognosis. The process, despite being perceived as a painful surgery, is a relatively comfortable procedure.

Implant Pros:

Implants are the closest restoration to natural teeth, replacing the lost root with a titanium post.

Implants have an excellent prognosis, likely higher than bridges long term.

Implants do not affect neighboring teeth.

Can be flossed individually.

Can be used in more extensive implant restorations in future if other nearby teeth have problems (see link below).

Implant Cons:

Require significant financial investment, costing around 25% more than bridges. This investment typically pays for itself however when amortized through life (they are far less likely to fail and need re-treatment.)

Take multiple appointments over several months.

Require adequate bone to support the implant fixture, sometimes the supporting bone can be improved through procedures, other times implants can not be placed if the bone doesn't offer a favorable prognosis (we do not chance it if we believe there is a questionable chance of success!)

In some cases, bridges offer a more esthetic option at the gum line if significant bone loss has occurred. We always evaluate this consideration in critical cosmetic areas.

More Extensive Options

Bridges are not limited to single tooth implants, however the longer the span and number of teeth involved, often the lower the prognosis becomes and the liability of multiple tooth failure increases.

The single tooth implant is the simplest use for dental implants. They are a workhorse that can be used for a variety of other applications. These include: bridges than span across multiple implants (not putting an implant under every tooth when a row of teeth are missing), providing a firm snap for dentures and partials to give retention and support, implants can support under-girding bars for very stable and attractive removable dentures that keep bone from being lost, and large fixed prostheses called hybrid fixed dentures that can be made with a variety of materials including acrylic and porcelain. For more information (and some real-life examples of our cases and our lab's work) on these exquisite options for missing teeth visit another of my blog posts: Modern Denture Alternatives.

 

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American Dental Association           American Academy of Cosmetic Dentistry            Pankey Institute Alumni