Free Dental Services: CDA Cares May 18-19, 2012 - Volunteer if you can!

Today I was reading an update article in our monthly news magazine from our California Dental Association (http://www.cda.org/) and there was one story that caught my eye that I want to share with you about a new event called CDA Cares
As I continue through my journey through dentistry I am learning more and more about legislation and public health issues, policies, and budgets. I truly feel that as the economy continues to fluctuate, and dental benefits, and budgets follow, the need and demand for education, public health and public service will continue to increase. With the loss of Denti-cal for under-served adults and the loss of many prevention programs for children, the need for ways to provide Californians oral care is great. And as dental professionals, with a program like CDA cares, it gives me hope that we are on the right track to meeting those needs.
On May 18 -May 19, 2012 in Modesto,  CDA and Mission of Mercy with a team of dental volunteers will put together an event that they hope will help thousands of under-served Californians with their dental needs.. .Hopefully one of MANY events that will provide FREE DENTAL SERVICES. According to the article most of the supplies will be donated or almost donated by many national dental manufacturers to make the event possible!! What I admired most was the emphasis on education & educating patients about oral health and options for continuation of dental care even after the two day event is over.
I was really excited to read about this event where the article states they hope to help over 1,000 people per day. There are many events like this all over (if you have heard of RAM - they had a health event at the Oakland, CA Coliseum April 2011 - hence the video). I have seen many and helped in many dental events - but after an event is over, we have helped these patients but we don't know when they'll be able to be taken care of again. Like fish in the sea, they are tossed back to fend for themselves, waiting for the next free event or being seen only on an emergency basis. I greatly admire and support this emphasis on education and helping patients find resources that will allow continued dental care is a HUGE step in the right direction. I help drug rehabilitation and homeless veterans, and volunteer at Give Kids a Smile day, I have helped in churches and soup kitchens. Giving to the community and underserved is something very important for me. And to have this kind of event, on such a large scale - as most Mission of Mercy events can be is very exciting in the dental world.
What I love about dentistry, and health professionals in general, is that generally we want to give and help others and educate them to take better care of themselves. Everyone wants to be successful in their life - but what are your measurements of success? Being good to your own family and cultivating and taking care of patients in your practice is a wonderful ability and measure of success. But also giving back, volunteering, being kind to others, helping to makethe lives of others better are successful things in my book.
More information will come on how you can help. If you are not in California, PLEASE look out for programs such as these. A WONDERFUL resource I found is: Free Dental Work http://freedentalwork.org. But if you can help for this dental event - as a dental assistant, as a hygienist, as a dentist, or technician - PLEASE mark your calendars and VOLUNTEER!!! I know I'm going to try and help!!! I am SO EXCITED about this!!!
image courtesy of: blog.sfgate.com

Pradaxa: Anti-Coagulants & Dentistry

Yesterday I had the pleasure of working on a very nice patient who also happened to be a physician! I was doing his examination & we started chatting and reviewing his medical history. He stated that he recently had been to Africa and unfortunately had become very sick and experienced: paroxysmal atrial fibrillation (abnormal rhythm of the heart) and was placed on a drug called: Pradaxa (generic name: dabigatran)
I learned two lessons today: 1) I was reminded how important it is for a medical history to be updated at each dental appointment, and 2) I met my first patient who was using Pradaxa (a new anticoagulant drug).
Now, I know that I am over-simplifying but if you have abnormal rhythm of the heart, the heart doesn't send blood out to your lungs and your organs efficiently and there are all kinds of problems that result from that - the most important being the increased risk of stroke (the 3rd leading cause of death & leading cause of disability - information courtesy of: Dr. Pullen - you can see his information here: http://drpullen.com/pradaxa)
But what I REALLY want to talk about from a dental standpoint is the medication treatment after being diagnosed with atrial fibrillation - which has always been an anticoagulant: either coumadin (aka: warfarin), IV administered HEPARIN, or ASPIRIN. But this patient was placed on PRADAXA.Why do I care as a dentist about anticoagulation drugs (such as warfarin/coumadin and now, Pradaxa)?
The reasons are many: to understand your comprehensive medical history, to expect more bleeding when a cleaning is performed, but MOST importantly because if I need to perform surgery or an extraction of a tooth, I need you to STOP bleeding after. If you can't clot because your blood is too thin, the extraction site is like an open wound that just keeps bleeding and can, if not caught, can lead to mortality. And that is DEFINITELY not something anyone wants.
I have seen Pradaxa commercials on television but I didn't know much about it. So of course, I looked up history and information of the drug. I am not a medical physician but here are a few things that I found:
-it was developed by the pharmaceutical company Boehringer Ingelheim.
- it was FDA approved October 2010 and approved to be put into effect February 2011 (so a relatively new drug - out less than a year)
- usually dosed to a patient at 150mg two times a day
- upon taking Pradaxa it is effective within a few hours of taking it vs. coumadin/warfarin where the dosage is a little tricky and you have to go in for tests all the time before you can get the dosage correct
- it supposedly has "fewer drug interactions" than warfarin
- as it is a new drug it is more costly & the long-term side effects are still not yet determined
Either way, from a dental standpoint it is important for me to be aware of this drug and put it on my "anti-coagulant radar" so that if I can be aware of any potential complications & plan your dental treatment accordingly. I am excited to hear that there is an easier alternative to coumadin - that can save lives and help in the prevention of stroke & further medical complications!
If I find out more I will let you know and keep you updated!! And if you see your dentist, please update him or her on your new medications. It could save your life!!!
image courtesy of: noprescriptioneeded.com

A "HOT" tooth - a not so hot experience

I'm sorry that today I have to share an experience that is NOT the most positive - but I CAN state that I learned MANY positive lessons today that I will share with you.
I have heard from many people that dental pain is on a pain scale all to its own. I hope and pray that I never have to experience it. You hear of people getting cuts and bruises, and spraining or breaking their ankle from sports injuries, even hip and knee replacements - which to me sound VERY painful. But it is my experience that there are people that would rather experience a broken ankle, or replace a hip joint, rather than experience dental pain. And today I vicariously lived through one of my patients who today was experiencing what we in the dental world non-scientifically term a "hot tooth". You ask: What is a "hot tooth"? Please read on...
You can find me, almost every Tuesday s at the VA Dental Clinic (veteran's affairs dental clinic) seeing patients and taking care of the homeless and drug rehabilitation patients. And today was no different and I was going through my day without significant incident. But then, this afternoon I took an emergency walk-in patient. As I passed the waiting room I could see a young man - his shoulders slouched, his head in his hands - very obviously uncomfortable. We brought him back and even before he sat down in the chair immediately he began moaning and said he was in SEVERE pain and had been off and on the past 3 weeks! Just as immediately he mentioned that he was a heroin addict - had been a user for many years and experienced a lot but NEVER in his life had he experienced this kind of pain.
I tried to remain calm - assured him that we would help him the best we could today and ordered an xray to be taken so we could see the problem. With just one look at the xray I knew the source of his pain was that one of his lower right molars had a HUGE cavity that had deteriorated to the nerve and had spread down below the bone. In short - we couldn't save the tooth and it would have to be extracted.
Now before presenting the options to the patient, I'd like to say that ALL the options would include giving him antibiotics and pain medication BUT in terms of actual treatment to get him out of pain today were: 1) administer local anesthetic to get the area numb and give him a little relief from the throbbing pain and give him a few days for the tooth to calm down and the bacteria to start to be flushed away 2) get him numb and do what is called a "pulpotomy" which is the first start to a root canal and relieve the pressure, still anticipating that the tooth would need to be removed, and 3) get him numb and extract the tooth.
But options 2 and 3 would be very difficult in this case and like MANY dental cases, this patient brought with him a little more complication.
WHY you ask? Why don't we just get him numb and get the tooth out?? Because there are many things to consider:
1) FIRST and MOST IMPORTANTLY this tooth is causing this patient SEVERE pain (on a scale of 1-10, 10 being the worst, this patient scaled his pain as 10) - meaning it is termed in the dental world as a "hot tooth". What do we mean by hot? Unfortunately it does not mean that it is attractive or sexy, but that it means that the bacteria have infiltrated the nerve so severely that it is causing a raging painful infection. When bacteria infiltrate and agitate the nerve so much, the environment changes to an ACIDIC pH environment. The ability for local anesthetic to work in an acidic environment is VERY difficult. The nerve fibers don't absorb the local anesthetic the same as if there were no infection - and therefore - the patient does NOT get numb as quickly, and sometimes doesn't get FULLY numb (which is why you hear people saying that they could feel everything) - and we DO NOT want that.
2) this patient has a history and current history of drug use and abuse. Most of these patients have a VERY high pain threshold and because of the recreational drugs (and sometimes even prescribed pain medication) many times these patients take MUCH longer to be affected by local anesthetic. Many times, the illness of recreational drug use prevents dental anesthesia to be as effective and the metabolism of anesthetics is different.
3) this patient exhibited dental phobia and was in severe pain - rationale and reasoning went out the window. Getting himself out of pain was his main objective. And when your sole objective is to get out of pain you are NOT making rational decisions, nor are you in control of your hands and motions.  Dental phobia, drug use, swearing and pain do NOT a great patient make. I understand completely that being in pain is not something ANY person would smile about - I'm just stating that if a person is normally afraid of the dentist WITHOUT an infection - imagine what they feel WITH an infection.
4) Lastly from a personal safety perspective - this patient was very strong, muscular, MUCH BIGGER than me, and had a history of drug abuse. While I'm quite strong, me standing next to this man, I could see myself swashed like a bug. Generally speaking (and I recognize that this is not always true) it is common to see many recreational drug abusers with many types of infectious diseases - some so severe as HIV and Hepatitis B and C (causing irreversible life changes and quality of life issues). Knowing that I would have to give an injection to a patient who was in severe pain with a sharp needle, inside his mouth, was NOT something I was jumping up and down to do. I COULD do it, but I didn't feel a 100% safe. And neither did my assistant. And listening to myself and safety is a top priority for me and for the future of my family. No matter the job - it is not worth the risk of doing a procedure if I don't feel safe.
So what did I do!?!
I did what any responsible clinician would do. I asked for help. Thankfully working at the VA I am surrounded by more experienced dentists that I can turn to for help. I asked one of my mentors, a staff dentist, to come in and help me. He agreed that antibiotics and pain medication were required. And agreed that the tooth was NOT saveable. But what he was able to do that I was not was that he was able to get the patient numb by giving him A LOT Of local anesthetic - to get the patient comfortable for a few hours until the antibiotics and the pain medication could enter his system and start fighting his infection.And he was going to see him tomorrow to get the tooth out. Because antibiotics and pain medication will only get a person so far, and then there is a possibility of the tooth getting reinfected again. He left, as happy as he could be in this situation, and MOST IMPORTANTLY: OUT OF PAIN.
I learned a LOT from this situation. There was the part of me was very disappointed that I could not do that myself - that my reservations and concerns based on my past experiences with "hot teeth" and knowing his medical history prevented me from going in and just giving him an injection to get him out of pain. BUT, I learned that listening to myself regarding saftey is not a weakness. I learned that asking for help is the responsible thing to do when I need it. I learned that I felt safer that who came to my aid in this situation was a STRONG CALM MALE (not necessarily that it has to be male but a dentist with a lot of dental experience) due to my concerns of SAFETY. And I learned that while I knew what the best plan of action was when a patient is experiencing a "hot tooth" that I shouldn't second guess myself about what to do. Next time I feel that I will know exactly what to do the next time a "hot tooth" and I cross paths...
Hopefully it will not be anytime soon.
image courtesy of: clipart.com

Deep Sea Diving & Dentistry- Connected??

This past weekend my brother told me of this diver earlier in July who was almost swallowed by the whale shark seen above. Immediately I googled the story and saw this CRAZY picture you see here - http://newsinabox.net/1721/whale-shark-photographed-when-almost-swallowed-a-man.html
Just as immediately, the dentist in me began to think of diving and related this story to MY work experience with diving. Who would have thought that dentistry and deep sea diving would be connected? While NO ONE in the world would want to be that young diver in the picture above - I learned this past week firsthand how divers and dentistry can be connected…
The other day I had a very nice patient come to our office with pain in his upper left jaw. He saw the hygienist for a cleaning and then I was asked to come in and evaluate the area and see what was happening. Even before seeing the patient my immediate assumption after hearing from the hygienist that he had a jaw problem was that he possibly had an infection, possibly had tension in his jaw due to trauma, or what was at the top of my list: that he had been clenching and grinding creating jaw pain. Nowadays I am more and more aware of wear on people's teeth from clenching and grinding ESPECIALLY in today's economy with no economic relief in sight and the need for a guard to help protect their teeth.
When I went in to check, it was not as I had suspected. He was healthy as a clam, no medications, and missing his upper left teeth – no clenching and grinding there! Then out of the blue he mentioned that he deep sea dived two weeks ago and he started noticing it getting worse after that. After he said that, it was as if a LIGHT BULB had gone on. AHA!!!!! Why?
Because deep sea diving = pretty extreme pressure changes! You’ve seen the movie The Abyss? Diving Pressure - yes! Human deep sea bottom dwellers - NO! As the diagnosis light bulb grew brighter in my head he said he remembered that when he had his tooth removed over four years ago that there had been a large hole in his sinus because the roots were very long and went right into his sinus cavity! Everything had healed but they had told him that he had a huge hole there after the extraction and they had packed it well and checked on him a few times after.
I had found my answer: his deep sea diving (and probably his flight home) had caused such extreme pressure changes that it had not allowed a complete equilibration of pressure in his sinuses. This increased pressure led to sinus inflammation and increased pressure in his gums! This even probably irritated the extraction site where there had once been a hole!
Now, for you (and for us dentists) it is GREAT to note that most of these communications will heal just fine on their own as long as the dentist/surgeon treats it appropriately (I will share more on this at another time). So why have pain NOW - years later after his extraction?
Perhaps he dove too deep and didn’t let everything equilibrate as slowly as he could. Perhaps he has allergies which cause inflammation of the sinus cavity – and that combined with the deep sea pressure and then the abrupt change in altitude with flying – all in combination irritated his sinuses. As you can see, while there is no ONE reason for this - there are MANY things to consider.
To help answer this: as a background - when you have teeth extracted in the upper left or upper right, towards your premolars and first molars sometimes the roots of those teeth can be VERY close, touching, or even EMBEDDED in your sinus cavity covered by a very VERY thin membrane. If this membrane is pierced or torn it exposes the sinus air cavities - allowing food, smoke, bacteria etc. a passage into your sinuses and drain into your nose and nasal passages leading to nasal inflammation, pain, and infection. NO ONE wants dinner from last night affecting their breathing. Yuck.
If this communication occurs it is called in the dental world: an oral-antral communication (aka: OAC)  – a serious word that basically means a connection between your mouth and sinus cavity and it must be treated accordingly If it isn’t treated  then an “oral-antral FISTULA” can be formed – a "tunnel" that is a PERMANENT link between the sinus and your mouth! If this occurs unfortunately the only option is surgery to close this link.
As I had said, most of these OAC’s heal just fine on their own. BUT like a scar on your skin, this area is weakened. So when you do various activities that involve changes in pressure or altitude (like flying or in this case deep sea diving AND flying), the sinuses CAN be affected! It is possible that he was only having pain on the left side of his jaw because that is the only area where his sinus had been perforated – weakening that area. Additionally if you have infection or sinusitis (inflammation) from sinus infections, this pressure can sometimes cause pain.
Lastly, something to consider is that after an extraction, most of us want to replace the tooth we are removing. It is important to know ahead of time, before the extraction, that the sinus cavities can expand and descend (a process called pneumatization) – sometimes descending too close to your bone and gums. This can make it very difficult to replace that tooth with an implant (or at least make the process of replacement MUCH longer and more involved than if you plan ahead of time). So PLAN AHEAD!
So what was I reminded from this experience?
1)      Never jump to conclusions before you start a diagnosis (I had thought he was clenching and grinding when in fact he didn’t even have teeth in the area he was having pain)
2)      Oral-antral communications can after an extraction and have long-term effects
3)      Sinus inflammation & changes in sinus pressure can cause pain and even mimic tooth pain
4)      Most importantly – I was reminded to ask medical history and listen when the patient tells you a background of the pain they are experiencing - such as if something happens AFTER an event. If this patient hadn’t told me that he had taken a recent trip and deep sea dived, I never would have considered that to be a connection to his pain and never been able to help him with his diagnosis
5)      Lastly, I realized that patient’s life activities affect their teeth and oral cavity in ways I hadn’t imagined. I truly would LOVE to try deep sea diving sometime, and if I do - EQUILIBRATE!!!
image courtesy of: pichaus.com

A dentist is cleaning your teeth??? Yes it's me!!!

Today I had a busy schedule - I was doing fillings, and crowns, and seating crowns, and finishing cases, while our hygienist also had a full schedule filled with exams and probings and xrays. It was a GREAT day. BUT I also had two appointments where I needed to do the works myself: the cleaning, the updated films, and the cleanings.
I'm not complaining about my day at all - but as I was performing the cleanings, each patient asked me "Aren't you the dentist? How come you are doing my cleanings?" My answer to this question was that "Yes I am a dentist, but I enjoy doing cleanings because I get a more comprehensive picture of you and I am able to spend more time with you." And these are very TRUE statements! But as of late I have been reflecting more and more on doing cleanings for patients and feel that, as with everything, there are pros and cons to a dentist doing cleanings.I have decided that there is a catch 22 with doing cleanings as a dentist.
Let me start with the positive because the advantages of a dentist performing your cleaning are many. When I'm doing a cleaning I am able to look around, get a sense of the patient's home care, feel cavities, discuss their hygiene, see excessive bleeding and inflammation, see where their body language shows that they are having pain in a certain area when I work there. Little innuendos that I cannot see when I pop in with my white coat, white coat syndrome makes the eyes go blank, and are often sadly lost! I am able to obtain a "whole picture" of the patient from start to finish of the appointment instead of popping in for an exam, seeing teeth already cleaned by the hygienist and they are anxious and ready to leave. Also, if a hygienist did the cleaning, the majority of the interpersonal contact has already been done with the hygienist - all the energy and rapport has been spent with someone else. I become the mean dentist that comes in to check and give them the news - thumbs up, or worse, the bad news about any cavities. So when I am able to do the cleanings myself the TIME with the patient, the interpersonal contact and the face-to-face time I spend with them is invaluable. If they need me for an emergency in the future, they can put a face to my voice or if they have enjoyed our previous interactions, they know and trust I am helping them - certainly trust me more than if they didn't know me at all!.
Now to the cons (the less positive) - while I enjoy cleaning teeth the fact remains that I AM a dentist and my time is more productive and better spent doing dentistry. Additionally I personally would like to be honing my dental craft and doing what I studied - crowns and fillings and bridges, and more complex cases. As an associate dentist I do a lot more cleanings than I would like - not again that I don't like doing them, but I would PREFER to be doing something else - challenging myself as a dentist and learning something new in the process. In the end I could do a darn good cleaning for you - but what about the rest because if I never get to do dentistry, I won't be able to learn and won't be able to tackle the more complex cases and won't have the experience to help a patient in need - because I've been busy doing cleanings.
For now, I am content in that I am able to have a happy medium where currently as an associate I get the best of both worlds - in that I am able to do cleanings and spend time with the patients, and I am still able to do the dental side of things and learn (like today). In the end I am able to embrace and enjoy and have a nice mixture of treatment in the day (hopefully I will do more treatment than cleanings in the future, but patience is my virtue!!!)
image courtesy of: funnyordie.com

Dentists - each a "Dr. Gregory House" of the dental world

 

I LOVE the show House on USA- I'm sure you've seen it. I saw the first entire season in two days on DVD the first time I saw it. You see Dr. Gregory House, a brilliant yet poor bed-side-manner doctor, with his team of doctors be presented with a very unique case and they are trying to figure out exactly what the patient has, usually life threatening. If you notice, they go through many different diagnoses before finally reaching the correct one. Well, tonight, I truly related that to dentistry and oral lesions!! We each are like the "Dr. Gregory House" in the dental world (most of us are MUCH nicer with excellent chairside manner) but we are similar in that we are trying to help you find out exactly what you have so we can treat it appropriately.

Tonight we had a Dental Society meeting and we had the pleasure of having an excellent speaker. He was an oral pathologist from the University of the Pacific and he gave a presentation about common oral lesions -signs, symptoms, diagnosis and the recommended treatment.His presentation was wonderful - replete with pictures (I am a visual learner) and examples of the various lesions and he had all of us give suggestions of what we thought those lesions were.
While many of the lesions he discussed were familiar - many a review of my dental school oral pathology class - one thing that I was reminded of is that many times patients come in with an oral lesion and many of the lesions look VERY SIMILAR to each other - meaning the diagnosis could be a NUMBER of things. When we ask you to open your mouth and we look around -we are looking for all lesions - from the most benign lesions to the most severe lesions (oral cancer - please see my "let us pull your tongue" dental post http://www.adentalperspective.com/2011/08/25/youre-pulling-my-leg-er-tongue/).
Burn lesions can resemble herpes lesions. Herpes lesions can look like Shingles (chicken pox re-manifestation). The little white and red patches on your tongue can be benign geographic tongue (which is a variation of normal) or a fungal infection (candida) or possibly even premalignant/precancerous lichen planus. The most severe traumatic lesions can even look like oral cancer!! Inflamed gums and pregnancy gingivitis can be mistaken for "desquamative gingivitis". Sometimes lesions on the skin can also be seen in the mouth and it means a more serious medical condition - such as target lesions (sometimes called erythema multiforme)
As general dentists we will do the best we can when you present with a lesion (or lesions) - step one is even recognizing that you have the lesion and start the diagnosis process and prescribe the best medication we feel is best. If the lesion remains or looks very suspicious we can send you to our colleagues (oral surgeons and oral pathologists) and they can continue to help you to perform evaluations and at the most severe - biopsy or surgically remove a lesion if it isn't eliminated. This is not done to scare you - it is done to help you and prevention and recognizing a lesion is the best first step.
In the end, I am reminded again that the oral cavity is the gateway to the rest of the body. Oral lesions can show systemic conditions - and sometimes are the first signs of an overlying and more severe systemic health issue. I will continue to educate myself - hopefully through such informative lectures like the one tonight, and hopefully be better able to recognize a suspicious lesion first so we can address it as soon as possible. It's 9.999 times out of 10 that it is nothing serious! But it's the other small percentage that is important!! Each of us are the "Dr. Gregory House" of the dental world - one oral lesion, one differential diagnosis at a time until we will get it right!!!

Some Free Samples from Proctor & Gamble

Proctor & Gamble is an amazing company with an even more amazing dental presence. What person hasn't heard of CREST, or whitestrips, or ProHealth mouthwash. They dabble in it all - from toothpaste to Tide. What is even more neat is that they are allowing many of their customers to try out a few of their products - they have a section where you can sign up for coupons and specials and even get free samples!!!
Right now I've had so many people come and ask for bleaching - but for those of you who want to try OTC first, right now you can sign up by going to their website link http://www.pgeverydaysolutions.com/pgeds/pg-brandsaver-samples-coupons.jsp and after signing up you get a cornucopia of fun items - not just dental - but the P&G Brand Sampler includes:
- FREE sample of Crest 3D White Whitestrips & FREE sample of Crest 3D White Vivid & a FREE sample of Head & Shoulders shampoo & FREE sample of Prilosec OTC!
Save, promote oral and physical health, and sample!!! That's a win for me!!!!