Xylitol – How to Use It, Where to Get It

Getting the cavity prevention benefits of xylitol depends on using the right amount at the right time. For adults and school age children, that means consuming 6 to 10 grams per day. It is available in several forms including chewing gum, mints, various types of hard and soft candies, granular (as a substitute for table sugar), mouthwash, toothpaste and mouth spray. It’s important that the first ingredient listed on the label is xylitol and it is very helpful to know the amount of xylitol in each serving so that you can be sure you are getting 6 to 10 grams a day.  (Avoid products that contain sorbitol or mannitol as the main ingredient and have xylitol in amounts too small to have any beneficial effect.)

Here are some tips on how to use xylitol products:

• Have 3 to 5 servings of any 2 gram combination of xylitol products daily so that total consumption is 6-10 grams. (More than 10 grams is okay as xylitol is very safe.)
• Consume after meals if possible.
• Try to make each serving last 5 minutes.
• Add to your diet gradually rather than all at once. 

Sources for xylitol products - A Google search will turn up many websites that sell xylitol. Here are some we like:

 

• Epic Dental (www.epicdental.com) - Good prices on gum, mints, bulk sweetener for use in coffee, tea and cooking, mouthwash, toothpaste.
• Dr. John (www.drjohns.com) - Dr. John specializes in all kinds of candies made with xylitol. Check out the tab called "Simply Xylitol" for specific suggestions on how to create your own program.
• Carifree (www.carifree.com) - This website has a lot of good information and high quality products. Click on the "Solutions" and "Cavities A-Z" tabs to see how xylitol (and other products) can be used for specific problems like dry mouth of bad breath in addition to dental decay. 
• Xlear (www.xlear.com) - Toothpaste, mints, gum, candy, mouthwash and nasal spray. Sold in stores under the "Spry" brand. Click the "Where to Buy" tab to find local stores that carry Spry products.

 CAUTION!  Xylitol is toxic  to dogs.

Side Effects – Add xylitol to your diet gradually rather than all at once. If eaten in large amounts too quickly, it can lead to gas, bloating and diarrhea. As the body adjusts, symptoms will disappear.

Xylitol - Who Can Benefit?

In my last post I noted that xylitol can reduce cavities by as much as 85% when used properly. It works by correcting the balance of acid producing bacteria in the mouth; that is, reducing the number of bacteria that produce acid and increasing the number that do not. In this entry we will look at who should be using it.

1.     People who get frequent cavities.  When bacteria are in proper balance, saliva flow is normal and the diet is low in refined carbohydrates, people don’t get cavities. If you have had a cavity within the last three years or especially if you have had multiple or frequent cavities, you are a candidate for xylitol.

2.     People who have dry mouth (xerostomia). We are seeing more and more patients with dry mouth syndrome, which often appears as a side effect of taking lots of medications. Nothing is more frustrating for us than to see patients who have had no problems for many years begin to get cavities as the number of meds they take increases.

3.     People who have physical problems that compromise their ability to brush. This often happens to people who are in nursing homes or assisted living.

4.     Mothers of newborn babies. Babies are born essentially germ-free but very quickly acquire the bacteria present in the mouths of their main caregiver through kissing, food tasting, etc. If the mother has good oral health, the baby is less likely to acquire the bad bacteria.

5.     Children whose permanent teeth have not yet erupted. Cavities in baby teeth are a sign that bad bacteria have already colonized a child’s mouth. If the child is old enough to chew gum or dissolve xylitol-containing candies in the mouth, the bad bacteria can be eliminated before the permanent teeth come in.

6.     People with poorly controlled acid reflux (GERD). In addition to minimizing bad bacteria, xylitol also changes the pH of the mouth to a non-acid environment. This reduces the likelihood of acid erosion damage to the teeth as well as reducing the possibility of decay.

If you suspect that xylitol would be beneficial for you please ask us about it at your next visit.

There is one more post to follow in the “xylitol trilogy.” In it, we will look at where to get xylitol, how to use it, and possible side effects.

Xylitol - Sugar That Prevents Tooth Decay?

For years I have been lamenting the effects of excessive sugar in the American diet. We see the dental consequences (namely tooth decay) as well as general health problems like Type 2 diabetes, on a daily basis. Our attempts to defeat decay by getting folks to reduce sugar consumption have met with less-than-complete success.  Now there is increasing evidence that it might be possible to indulge your sweet tooth without the risk of decay.

The potential answer is xylitol. It’s a natural sugar, not an artificial sweetener. It is derived from corncobs or corn stalks but is NOT like high-fructose corn syrup. It looks and tastes like table sugar but has different chemical composition and 40% less calories. It also has a low glycemic index and is not metabolized by insulin, making it ideal for diabetics.

Sucrose, the chemical name of good, old, cavity-producing table sugar, is digested by  oral bacteria to produce a sticky, acid slime that coats the teeth. This acid biofilm dissolves the calcium in tooth enamel and causes decay. In the presence of xylitol, however, the bacteria can't produce either the acid or the sticky slime so the bacteria just slide off the teeth. Because there is no acid, the calcium stays in the enamel where it belongs. In fact, there is evidence that, in the presence of xylitol, there is actually enough calcium in saliva to remineralize small cavities. Reputable studies have consistently shown up to an 85% reduction in decay when xylitol is used in the correct doses.

There is a lot more to the xylitol story, including how to use it, where to get it, side effects and the fascinating idea that it can be used to prevent future decay in unborn children. We will cover all of that in future posts, so stay tuned. 

Forty Years of Dentistry

As of two days ago, I have been practicing dentistry for forty years. It hardly seems possible that it could be that long because I really do not have any sense of the passage of such a long period of time. I look forward to going to work more than I ever have,  but what has passed has sort of disappeared into the void, almost as if it never happened. I guess if I had it to do over I would do some things differently, but on the other hand, I don't think I would have the same level of satisfaction with my career if I had not had the experiences that I have had. I don't think I would be as grateful for the good things I have in my professional life if I had not had the not-so-good things as a source of comparison.

There was an article in the May 27 issue of the New York Times called "Let's Be Less Productive." It addressed the world's relentless pursuit of greater productivity and efficiency and brings up the question of what happens to the number of jobs available as we get more efficient and the cost to the environment as we pursue ever greater levels of productivity. The author, Tim Jackson, points out that there are sectors of the economy where chasing growth does not make any sense - such as medicine, social work and education - what he calls the "caring professions." He says, "Time spent by these professions directly improves the quality of our lives. Making them more and more efficient is not, after a certain point, actually desirable. . . The care and concern of one human being for another is a peculiar 'commodity.' It can't be stockpiled. It becomes degraded through trade. . . Its quality rests on the attention paid by one person to another. Even to speak of reducing the time involved is to misunderstand its value."

Looking back on my forty years of practice, there is no other single factor that has contributed to my sense of satisfaction and fulfillment as much as my decision several years ago to stop pursuing efficiency and allow enough time to meet the relationship needs of my patients. (And, it turns out, my own relationship needs.) This is not to say that taking more time drags out the sometimes physically unpleasant experience of dentistry for my patients. Allowing more time does not mean that the actual dentistry is done slower. It does mean that I am not rushing from one procedure - or one patient - to the next. Allowing more time does not necessarily improve the technical quality of the dentistry but it definitely does improve the quality of the emotional experience in my office. This is true for the patient, for me, and for my staff.

Medicine and to a lesser extent dentistry are at a turning point regarding delivery of care. There is no question that, as a nation, we can no longer afford the medical delivery system we have. In the painful and politically charged debate about what is to come next, I have heard a lot about reducing cost and almost nothing about improving the quality of the patient's and the clinician's experience. There is a lot of talk about improving patient outcomes. Unfortunately, I think the measurements for determining outcomes mostly have to do with statistical measures of results and tend to leave out the quality of the patient's experience. It is one thing to determine which treatment will be successful for a given disease. There are statistics that can document that. In my experience however, the skill, care and judgment involved in determining the appropriate treatment for an individual human being is far more complex and requires a great deal more time than simply determining the treatment for a given disease. It's more than a matter of doing the right treatment. It is a matter of doing the right treatment for each individual patient. What is appropriate for one patient may be absolutely wrong for another even though the disease process is the same. To make the determination of what is right for an individual it is necessary to get to know and build trust with that individual. Given enough experience and skill it is possible to do it, but I don't know any way to do it that doesn't involve uninterrupted time, attention and the ability to get your own agenda out of the way so you can listen - really listen - to the patient. Forty years of experience have enabled me to do that and, more than anything else, accounts for the pleasure and satisfaction I find in my work.

So after all those years of dentistry, the main thing that I feel is gratitude. I am grateful to be able to say that I enjoy going to work every day. I am grateful to work with the people I do. I am grateful that my health permits me to do what I do with a high degree of skill and awareness. I'm grateful for the satisfying relationships I have with so many of my patients. I'm grateful that so many of them have been a part of my life for much of my forty years. I am grateful that I have been successful enough that I can now work because I want to, not because I have to. I am grateful that I truly enjoy the people that I work with and that it is not an exaggeration to say that we love each other. And I am especially grateful that forty years of working with people and working on myself have given me the wisdom to be able to get out of my own way, at least most of the time.

Are We Killing Our Kids?

Hardly a week goes by that we do not see a teenager or twenty-something with extensive decay between the teeth. This happens even though the patient has had topical fluoride every six months for their entire life. The most recent case was a seventeen-year-old with beginning decay between many of his back teeth. The cavities were not visible to the naked eye but were very obvious on x-rays. This young man’s  physician told him that he might benefit from the electrolytes in sports drinks, so he was drinking two or three large ones every day. I don’t know whether the electrolytes were doing him any good, but I do know that the acid and sugar in the drinks were rotting his teeth away. It’s more than a little depressing to me that a physician would recommend these drinks as a health benefit without considering the potentially huge negative consequences.  

This is an enormous problem – and not just because of the teeth. In the last twenty years there has been a 1000% increase in type 2 diabetes in children. (This is also known as adult onset diabetes.) Forty percent of children are now overweight. Of those, almost 2 million are morbidly obese, meaning that they exceed the 99^th percentile for weight. The average American drinks 54 gallons of soda every year. The average child in America consumes 34 teaspoons of sugar EVERY DAY. We consume 600 more calories per day from sugar than we did thirty years ago. The cavity problem is only the tip of the iceberg. To be blunt about it, the American diet is killing our kids.

When it comes to cavities, sometimes we can motivate a patient to change the specific dietary habit (often soda) that is causing the problem. Unfortunately, one-on-one counseling is not going to have much effect when tens of millions of children are overweight. This is a social problem and it demands a social cure. If it’s going to get fixed, it needs to start in our homes, schools, and communities and must encompass changes in government policies and industry practices. Does it make sense to have the government subsidize production of high fructose corn syrup? Is it wise to allow food stamps to be used to buy soda when they cannot be used to buy alcohol and tobacco? Tobacco and alcohol are regulated because we recognize the social costs attached to their use. Why not sugar? One of our great social problems is figuring out how to pay the cost of medical care, yet we actually subsidize one of the causes of a very significant chronic disease.

So I cheer when Mayor Bloomberg of New York City proposes a sixteen ounce limit on soda sales. I’m in favor of proposals to tax sugar and sweet drinks. What I hope for is a national awakening much like what happened beginning in the sixties regarding smoking. I know that it will not happen overnight but I see signs that things are beginning to move in the right direction. In the meantime, we will continue to put fluoride on kids (and sometime adults) teeth. We will increase our vigilance for the telltale signs of decay. And we will continue to nag you about diet, knowing that tooth decay can be an indicator of an even more serious metabolic problem.

X-rays and Brain Tumors

There has been a great deal of controversy about a recent scientific study that associates dental x-rays with meningioma, a common brain tumor. Understandably, this has raised questions from some of you about the safety of x-rays in general and dental x-rays in particular.

Meningioma is the most common brain tumor and occurs in about 15 out of every 10,000 people. It is a benign tumor, which means that it is not cancerous. The study found that people who had dental x-rays were slightly more likely to have meningiomas than those who did not. While there are some questions about the validity of the technique used to determine the patients’ x-ray exposure, (the researchers relied on the patients’ memory to guess at how many x-rays they had) the results of this study generally agree with similar ones done in the past and simply confirm what we have known for years – any kind of x-rays are to be used with caution. In other words, this is not big news.

To put this in perspective, the average American gets about 700 times more ionizing radiation from the environment and from medical procedures than from dental x-rays. Radiation is in sunlight, in the air, given off by building materials, and in cosmic rays from space. Unless you wear a lead suit, including a helmet, there is really no way to escape radiation exposure. But even given the fact that radiation is everywhere and that dental x-rays contribute only a minimal amount to the overall dose, it still makes sense to minimize exposure wherever possible.

So what changes do we plan to make based on the new study? Other than spending more time discussing the issue, we do not plan to do anything different. That is because we are already doing everything we can to minimize radiation exposure. We follow the principle known as ALARA: As Low As Reasonably Achievable. That means we take the minimum number of x-rays to diagnose and treat a patient safely. For example, we determine the frequency with which diagnostic bite-wing x-rays are taken (the ones we take at your recall appointment) by the conditions in your own mouth, not by a set of general guidelines.   Every time an x-ray is taken in our office, you are covered with a lead shield that incorporates a thyroid collar. For over ten years we have been taking only digital x-rays, which produce a significantly lower dose of radiation than conventional ones. In fact, the author of the study admits that the past exposure levels on which the study is based were much higher than they are today. In addition, our modern x-ray equipment is registered and tested by the State of Delaware. Given all these precautions, we believe that the risk of NOT taking appropriate x-rays far exceeds the risk of taking them.

Some patients ask, “Why take x-rays if nothing is bothering me?”

The main reason x-rays are used at all is that they find disease at an early stage – before it starts to hurt. We find tooth decay, gum disease, early abscesses, cysts, impacted or missing teeth and tumors, among other things. Early treatment of these problems is easier, cheaper, less painful and often prevents tooth loss. X-rays are one of the big reasons why most of our patients in their seventies, eighties and nineties still have their own teeth.

Some say, “I don’t care. I’ll just take my chances without x-rays.”

That’s your choice, of course, but it does raise legal and ethical problems for us. Taking appropriate x-rays is the Standard of Care and failure to do so is malpractice. We understand and respect your beliefs, but if you really want ongoing care without x-rays, we can’t be your dentist. Some of our patients have even offered to sign a waiver absolving us of responsibility if we don’t take x-rays. Unfortunately, that won’t work either. We are not allowed, nor do we want, to do negligent dentistry, even if the patient asks for it. The only option for a patient who insists on having treatment without x-rays is to find a dentist who is willing to take the risk – and good dentists won’t.

This study doesn’t really tell us anything new about dental x-rays. Our goal is to do our best to keep your teeth and gums healthy and attractive. As always, we are happy to discuss your concerns.

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.