A Whole New Meaning for Thanksgiving

Once in a while, something happens that causes me to see the world through new eyes. It's usually a surprise event that makes me realize that the life I take for granted is not guaranteed and that major shifts can take place at a moment's notice. Such an event happened to my wife, Chris, and me on Thanksgiving Day. The turkey was in the oven and all was ready for our guests to arrive. She went out at about 2:30 pm to feed our horses before putting the final touches on the meal. After I while, I realized that she had been gone for an inordinately long time. I went to look for her and found her lying in the field. One of the horses had spooked and run over her. She was conscious but could not move and was in extreme pain. A 911 call summoned an ambulance and we took a trip to Christiana Hospital. It was determined that she had broken her hip. Early the next morning she had a total hip replacement. As I write this, it is just a month after surgery and fortunately she is doing very well. A full recovery is expected.

I learned several things from this experience. First, life is fragile and everything that we take for granted can change at a moment's notice. A broken hip is no fun, but she will mend. Had the horse hit her at a different angle, the result could have been much more severe and life-changing. Second, our current medical system takes a lot of heat from politicians and pundits but in our experience the care that is available is remarkable. Everyone, beginning with the EMS technicians and ending with the post-operative therapy staff, was skilled, caring and patient-centered. I am very glad that the accident happened here, rather than in some far-off, third world country. I shudder to think what might have happened if it had occurred in the African bush rather than at home.

As a result of all this, Thanksgiving has taken on a new meaning for me. I am approaching the new year with gratitude. I'm grateful for what we have in this country. Grateful that the accident was no worse. Grateful that we have first-rate care available to us. Grateful that, despite the administrative and funding mess that plagues our medical system, the people that provide care are able to put patients first. Grateful to be alive and healthy.

I'm not big on New Years resolutions, but I think this year I'll resolve to live in the present and appreciate what I have.

Dry Mouth

Patients with dry mouth, also known as xerostomia, are becoming more and more common, mainly due to the increasing number of people who are on multiple medications. It's a big deal because it is uncomfortable and because it can lead to rampant tooth decay. There is nothing more frustrating than to see a patient who has had healthy teeth foe many years suddenly begin to develop decay problems. In extreme cases, it can actually lead to the loss of teeth. The information below is from a handout we are designing for patients who have this problem.

Dry mouth occurs when normal saliva flow is interrupted for some reason. It most often occurs as a side effect of taking medications but also happens after chemotherapy or radiation treatment to the head and neck for cancer. There are also certain autoimmune diseases that result in dry mouth.

Xerostomia is an uncomfortable and potentially dangerous condition. Saliva acts as a lubricant, so without it the membranes in your mouth can become dry and cracked making eating and swallowing uncomfortable. Saliva also acts as a buffer, counteracting the acid produced by decay-causing bacteria. When your mouth is acid, decay can occur very quickly, even if you have not had cavities for many years.

There is no predictable cure for dry mouth. The best we can hope for is to manage it in such a way as to keep you comfortable and prevent decay. Some things you can do right away to begin the process are:

·         Carry a water bottle and take frequent sips to keep your mouth moist.

·         Use a humidifier when you sleep.

·         Minimize your intake of caffeine and alcohol.

·         Avoid mouthwashes containing alcohol. (Listerine Zero and Smart Mouth are alcohol free.)

·         Avoid sweet, sticky, spicy or acid foods.

·         AVOID CANDIES OR GUM CONTAINING SUGAR, LEMON OR CINNAMON !!!!!

·                             Avoid toothpaste containing SLS. (sodium lauryl sulfate)

             
              Non-Prescription Products 
                      Biotene Products (Available at  pharmacies and online www.biotene.com)

o    Oral Balance Gel

o    Mouth Spray

o    Liquid

o    Oral Rinse

·         OraMoist Disks (Available at Rite Aid or google “Oramoist disks”)

·         Xylitol gum and mints (Spry brand available at Harvest Market in Hockessin, the Vitamin Shoppe on Kirkwood Highway and online at xlear.com Other varieties at epicdental.com,)

·         Xylimelts (Avaliable at the office or online at orahealth.com)

·                             Boost Spray (Avaliable at the office)

·                             Carifree Treatment Kit (Available at the office)

         Prescriptions

·         Numoisyn Liquid and Lozenges

Comitting Suicide One Soda at a Time

As a dentist, I am on a permanent crusade against sugar because of its negative effect on teeth, but I’m beginning to think that tooth decay is the least of your worries if you are a big soda consumer. Here are some disturbing facts from a recent article in Bottom Line Personal.

The American Heart Association says that the safe upper limit for sugar consumption (above what is naturally present in foods) is six teaspoons for women and nine for men. Simple enough. But a 12 ounce can of cola contains 10 teaspoons of sugar. So do bottled iced teas and sports drinks. Even real fruit juices like orange, grape or apple contain about 10 teaspoons of sugar per 12 ounce glass. (It’s true that fruit sugar occurs naturally, but it creates the same disruption of body chemistry as added white sugar.)

So how many servings of these drinks do you consume in a year? If you are an average American, it’s 600 cans of soda and 125 12-ounce servings of juice. When you do the math, that’s about 7300 teaspoonfuls of sugar. American Heart Association guidelines are about 2000 teaspoons for women and 3000 for men. 

Without getting into the gory details, in addition to tooth decay, excess sugar consumption is associated with calcium depletion (as in osteoporosis), diabetes, autoimmune diseases, high blood pressure, pancreatic cancer, gout and asthma, just to name a few. These are all chronic diseases, meaning that they gradually diminish our quality of life. Said another way, we are killing ourselves a little bit at a time.

So what can you do? Switch to diet soda? I’m afraid not. In a study of 2500 people, those who drank diet soda daily were 61% more likely to have a heart attack or stroke than those who didn’t. On top of that, it’s hard to quit soft drinks because there are actual withdrawal symptoms, like headaches and cravings. Here are some strategies for quitting – switch from soda to fruit juice and water it down – about 25% juice and 75% water. If you like fizzy drinks, mix soda water with fruit juice or iced tea, about 50% of each. You can also add lemon slices or a little pureed fruit to good old water. There are a few commercially available beverages that are acceptable. Look for brands like Metromint or Hint. Be careful of so-called health drinks like Vitamin Water, however. Reading the label may reveal high sugar levels even though the name implies otherwise.

I have one more observation. Unless you have been living in a cave, you know that health care costs are one of the biggest economic challenges we face as a nation. The folks we have put in Washington don’t seem to have the slightest idea how to deal with it. What do you suppose the long-term economic benefit of reduced sugar consumption might be? Have you heard anyone in Washington talk about it in a serious manner? Neither have I.

Lifestyle Choices and Heart Disease

For over 25 years I have been a participant in the Healthcare Professionals Follow-Up Study (HPFS) sponsored by the Harvard School of Public Health. It is the world's largest, detailed long-term study of men's health. I fill out periodic, detailed questionnaires about my diet, exercise patterns, medical issues that develop and medications. The study has access to my medical records and occasionally even takes blood samples.What they seek to learn is the effect that dietary and lifestyle choices have on disease. 

In their recent newsletter, they reported on cardiovascular disease (CVD). While we all know the risk factors for CVD, I was astonished at what a large difference lifestyle makes. For example, men with a body mass index of 30 or higher (categorically obese) have more than DOUBLE the risk of skinny guys.

They also analyzed "low-risk lifestyle" choices which include prudent diet, regular exercise, weight management, moderate alcohol consumption and not smoking. Men who achieved all five of these factors had a whopping 87% lower risk for CVD than those who achieved none of the factors. Even men who were taking medications for high cholesterol or high blood pressure showed lower disease incidence if they maintained a low-risk lifestyle in addition to the medications.

I was pretty much blown away by these numbers. We all know that low risk behavior makes us healthier but I had no idea that the magnitude of the effect was so great. I guess I'll keep eating salads and working out at the Y.

VELscope and Oral Cancer

We have been using the VELscope in our oral cancer screenings for several weeks now. It's basically a high-tech, filtered, blue LED light that makes abnormal soft tissues in the mouth look different from normal tissue even before it changes enough to be seen with the naked eye. It's quick and painless and has met with overwhelmingly positive response from our patients. The idea is that the earlier we can find a problem, the better the chance of successful treatment.

Obviously, we can see more with the VELscope that we can without it. But using it has made me realize just how much we cannot see, no matter how carefully we look. We can't see down into the throat and in most cases, we can't really see the tonsils. Unfortunately,  these are areas where oral cancer is occurring more frequently in younger people. In a way, the VELscope is a metaphor for what happens in dentistry (and medicine, for that matter) every day. No matter how hard we try, it's impossible to find everything. High-tech stuff helps, but it is not a magic bullet. And we can't overcome the damage that occurs from harmful everyday habits. Treatments like filling a cavity or surgically removing a cancerous lesion are never as good as preventing the problem in the first place. I'm glad to have the VELscope, but I would be even happier if I didn't need it. Wouldn't it be great if no one smoked, or ate refined carbohydrates, or engaged in behaviors that encourage the spread of Human Papilloma Virus (HPV), a leading cause of oral cancer in young people? The VELscope is a cool thing to have and makes a big impression with many patients. Prevention, on the other hand, is not very dramatic but it is, by far, the best tool we have. 

Necessity is the Mother of Invention

On March 29, fresh from a trip to Viet Nam, I made a post about the difficulty of crossing the street in a small country with a lot of busy people and 25 million motor scooters. There's a lot more to the motor scooter story, however. If a motor scooter is your only means of transportation and an important part of your livelihood, you can use it for things that would never occur to those of us who have the luxury of having minivans and SUV's. In Viet Nam, the lowly motor scooter is family transportation, a commercial vehicle and a beast of burden among many other things, I saw scooters carrying dozens of live baby ducks, every conceivable fruit and vegetable, chickens, a side of beef, hundreds of eggs, hay and straw, flowers, stacks of cardboard for recycling, twenty foot long bamboo poles, giant bales of stuffing for furniture and the furniture itself. As long as the kids are little, it's no problem at all for a family of four to go on an outing with the sleeping baby wedged between Dad, who is driving, and Mom on the passenger seat while big brother sits in front of Dad. All kinds of things are sold from scooters. I saw basket vendors, brooms and brushes, pizza, a toy store and lots of mobile bakeries. I watched two guys weaving their way through traffic while carrying a full length mirror. But the most amazing thing of all is in one of the attached photos. Our guide in Hanoi, Huy, needed a new refrigerator. Rather than pay extra to have it delivered in a truck, he recruited one of his buddies who balanced it on the back of his scooter and made the delivery without incident.

Invisible High Tech

I recently took a CE course from Dr. Larry Emmott, who is regarded as the guru of high technology in dentistry. I was amazed to find that half of the offices attending the course did not use digital x-rays, did not have computers in the treatment rooms, and did not have a website. We have been using all these things for over ten years and it got me thinking about how, after being in place for a little while, technology sort of disappears into the infrastructure and gets taken for granted. For example, it's not obvious to our patients that computers in the treatment room mean that all their records are accessible from anywhere in the office without having to find a paper chart. Once an entry is made in a chart from anywhere in the office, it is accessible for front desk check-out, submission to insurance, for review by doctors, hygienists and assistants. Nothing gets lost. Nothing gets misfiled. We never find unidentifiable x-ray films on the floor because they have fallen out of someone's chart. (There are no films because the x-rays are digital.) Chances of a bad treatment outcome due to lack of information or, even worse, incorrect information are reduced dramatically.

When we moved into our present office over ten years ago, I remember how I almost choked on the amount of money needed to purchase and install the high tech systems. This course reminded me of what it used to be like in the olden days before we had them. Now I cannot imagine working without them.

Crossing the Street in Viet Nam

I'm traveling in Viet Nam and this is being written in Hanoi. The Viet Nam war was one of the defining events for my generation and I approached this trip with mixed feelings. But Viet Nam in 2011 is a far different place than it was in the sixties. The population is now about 90 million - more than double what it was when the war ended in 1973. Half are under age 35. There are also 25 million motor scooters. They are EVERYWHERE. Add millions more cars, trucks, bicycles and buses and you have a situation where taking a stroll is a big adventure. As best I can determine, here are the rules for getting across the street in one piece.

#1. Size matters. That means a bus is king of the road and pretty much goes wherever it wants. If a pedestrian, a motor scooter or even a car gets in its way, there is going to be trouble. As a courtesy, however, the driver will invariably honk the horn before he squashes you.

#2. Cars wish they were buses. They get frustrated because they are either cut off by the buses or boxed in by a swarm of motorbikes. The only thing left to intimidate is a pedestrian, particularly a bewildered tourist. It's best to try to avoid them at all costs. This, of course, is impossible.

#3. Motor scooters behave like people, except they have engines. Because their operators are out in the open, just like you, they are much more considerate than cars or buses and they will actually try to avoid you if you find yourself marooned in the middle of the street. However, they travel in large herds much like the Wildebeest in Africa. As an American-style pedestrian it is hard to get used to the idea that they they won't head straight for you when you step off the curb.

#4. Sidewalks are not safety zones. Trying to escape the stampeding herd of scooters by jumping back onto the sidewalk will not work. When things get too crowded on the street, the scooters use the sidewalk instead. They might also come out of an alley or even a storefront and sneak up on you.

#5. Traffic control measures such as stoplights and lane markers are regarded as amusing suggestions rather than rules to be obeyed. An open lane is regarded as an opportunity for a scooter to break away from the herd, even if the opening is on the wrong side of the street.

Given these rules, the question is - How do you get from one side of the street to the other without grievous bodily harm?  First, pay attention to everything around you. Being distracted from the task at hand by talking on your cell phone or to your traveling companion is a recipe for disaster. Second, keep your goal in mind. You want to get to the other side of the street. Move deliberately in that direction, even if it appears suicidal. Third, don't make any sudden moves. Don't chicken out and back up. Above all, don't try a quick sprint toward apparent safety. It's harder for someone to avoid you if they can't tell what you are going to do next. Fourth, have faith that everything is going to turn out okay. This is the toughest one of all. Believe it or not, the scooter drivers just want to get where they are going. Running over a pedestrian, especially a tourist with money to spend, would be bad for the local economy as well as inconvenient for you.

It turns out that Vietnamese motor scooter operators are incredibly skilled drivers who mean you no harm. They just play by an entirely different set of rules. The trick is to understand and respect those rules, then act  accordingly.

Come to think of it, life in general might be a little bit easier if we approached with the same level of attention and trust as crossing the street in Viet Nam.

Diet Soda, Heart Disease and Teeth

A study published in the July issue of the American Heart Association Journal has caught my attention. For years, we have been reluctantly recommending that soda drinkers switch from regular soda to diet soda because of the high sugar content in regular soda and its relationship to tooth decay. (We would much rather see no soda at all in your diet, but until now we thought that diet soda was more or less acceptable.) This study shows that people who consume significant quantities of diet soda have a 48% increased risk of heart disease. That’s a lot, and the more diet soda consumed, the greater the risk.

          This is not to say that diet soda necessarily CAUSES heart disease, but that it is ASSOCIATED with it. The current thinking is that people who consume lots of diet soda also tend to eat more fatty foods, more empty calories and exercise less. In other words, diet soda is part of an unhealthy lifestyle.  Apparently diet soda is one of the factors that leads to what is known as metabolic syndrome – a combination of high blood pressure, excess fat around the waist, high triglyceride levels, elevated insulin and low levels of HDL or “good” cholesterol. It’s metabolic syndrome that causes heart disease.

          The dental problem with diet soda is that it causes alarming levels of enamel erosion in kids who drink a lot of it. The enamel is gone within a year or two of the time the teeth erupt into the mouth. Diet soda contains phosphoric or citric acid and these acids can dissolve away the enamel in a very short time. Once it’s gone, there is no way to get it back. As a result, these kids often need crowns at a fairly young age to protect the underlying tooth structure. I have always thought that anything that eats the enamel off your teeth is probably not very good for the rest of your body and now there is a study to prove it.

          I think that maintaining a healthy lifestyle in our society is difficult for many reasons, but that’s a subject for a whole ‘nother blog. (Or several more, for that matter.) In the meantime, what to drink? The boring truth is that water looks like the healthiest choice.  

I'm here in Utah, having just taken Gordon Christensen's "Annual Update" continuing education course. He is arguably the finest dental educator in the country, if not the world. What makes this course so valuable to me is that Gordon is a practicing dentist just like me, but he also runs an independent testing laboratory that has no tie-in or financial support from any manufacturer. 

Most people would assume that the FDA or some other federal agency tests or regulates the materials that are used in your mouth. Not true. Manufacturers do their own research and in some cases manipulate the testing to get the most favorable results. Once the product is on the market, the real testing happens "in the field" - that is to say, in patients' mouths. This is NOT a good situation. What Gordon Christensen does is perform clinical trials on real people, publish the results, and teach several courses every year to get the word out on what works and what doesn't. I have subscribed to his newsletter for many years and consider it the single most valuable resource to ensure that I am doing the right thing for my patients. 

After taking this year's edition of the course, I feel very good about what we do in the office. We are providing good value for our patients. There will be just a few incremental changes to incorporate improved products and we will consider adding some new technology that has proven benefits, but that's about it.

It's nice that this particular course was given in Utah. My only brother lives in Seattle, so we rarely see each other, but he just bought a ski house in Park City. Consequently, I can get educated, visit the family, and do a little skiing at the same time.

Frustration and Hope - CAMBRA

Life does not seem to have any shortage of frustrations. Getting this blog up and running has been one of them and so, frustration being fresh in my mind, it's a good time to launch into my struggle to deal with one of the ongoing frustrations of my entire dental career. There is a small but significant number of patients who get decay no matter what we seem to do. What's more frustrating, the number seems to be growing. It's becoming more common to find a patient who has had no decay for 30 years begin to get cavities on the roots of teeth and around otherwise serviceable fillings and crowns. Until recently, our only real tool for dealing with this was high-dose fluoride prescription toothpaste. It was a hit or miss proposition.

I recently took a enlightening CE course that gave me reason to hope there is help for this monumentally frustrating problem. It's CAMBRA, short for CAries Management By Risk Assessment. Essentially, it's a way to determine who is at risk for decay, evaluate the risk factors particular to that individual, and prescribe targeted treatment using a combination of approaches.

The latest research tells us that tooth decay is an infectious disease caused by acid-producing bacteria. If the bacteria produce acid and the acid is not neutralized by saliva, sooner or later the teeth begin to dissolve. When we fill a cavity, we are not actually treating the disease of tooth decay. We are treating the RESULT of the disease. What we want to be able to do is treat the disease itself. That's what CAMBRA enables us to do. It gives us a number of ways to reduce the amount of time that acid is in contact with the teeth so that no damage occurs.

The process works like this:

• We determine who is at risk. This involves a visual and xray examination that looks for specific signs of disease much like the exam that we do when you have your teeth cleaned
• We analyze for factors that cause the risk. We might look at dietary habits, sugar consumption, quality and quantity of saliva, etc.
• We test for acid producing bacteria. This is done with a new type of quick, painless saliva test. This test is revolutionary because, for the first time, we can actually measure disease activity. 
• A treatment regimen is designed to minimize risk factors and increase things that will protect against decay. This usually involves some combination of special rinses, neutralizing gels, various types of fluoride treatments, sealants, etc. 
• After 3 months of treatment we repeat the test for acid-producing bacteria. If the levels are reduced we design a maintenance program to keep them that way.

This is a really big deal for us and for you. At last there is hope that we can deal with a process that has defeated our best efforts for years. It's simple, painless and pretty inexpensive. It does require that the patient make some lifestyle changes and use the rinses and gels at home. It also requires us to completely change the way we think about tooth decay and develop a whole new way of seeing. It's a paradigm shift for us and that may be the hardest part of all.