Recent Studies You Should Be Aware Of
May 22, 2012
I have preached for years, based on the information available, that there was a direct relationship between gum disease, heart disease, stroke and other health issues. This morning I received an email from the American Dental Association (ADA) about the newest report on this subject.
A report published recently in Circulation, the journal of the American Heart Association (AHA), states that current scientific evidence does not establish a direct cause and effect relationship between gum disease and heart disease or stroke. Additionally, the evidence does not establish that gum disease increases the rate of heart disease or stroke.
The report was developed by an AHA expert committee comprised of dentists, cardiologists and infectious disease specialists. The ADA’s Council on Scientific Affairs appointed a representative to the committee that examined 537 peer-reviewed studies on the subject in order to develop the report. The CSA then reviewed the report and agreed with its conclusions.
The report acknowledges the value of good oral hygiene to maintain good overall health but noted that current scientific data does not indicate whether regular brushing and flossing or treatment of gum disease can decrease the incidence of atherosclerosis, which is the narrowing of the arteries that can lead to heart attacks and stroke.
Last week, in typical media-slanted coverage, was a study published in Cancer, a scientific journal of the American Cancer Society, associating yearly or more frequent dental X-rays with an increased risk of developing meningioma, the most commonly diagnosed brain tumor. This type of tumor is usually not malignant. The study has received widespread media coverage, and a number of the stories cite the ADA’s dental x-ray recommendations that help dentists determine how to keep radiation exposure as low as reasonably achievable.
Study participants averaged 57 years old and were asked to remember how many x-rays they received as kids before age 10. That’s a stretch for believability – remembering details from 47 or more years ago? That long ago, x-ray technology was vastly different from today. When I was a kid, I probably got 100 times more harmful radiation from x-rays than kids (or adults) today.
Statistics show about 5,000 of this type tumor diagnosed each year in the U.S. In a country of over 310 million people, 5,000 is less than .001%. And, there are almost certainly many other causes other than dental x-rays. Granted, every brain tumor is serious, particularly to the person with the tumor and his/her loved ones, and the topic must be approached appropriately.
So, what do these two recent studies mean to you as patients and “us” as dentists? To be honest, not much for most of us. The fact remains that if you have untreated or uncontrolled gum disease, which has a strong genetic component, you will lose your teeth but apparently won’t die from it. And, if you don’t go to the dentist regularly and/or refuse dental x-rays at appropriate intervals, you put yourself and your dentist at significant risk.
Studies like these are important for the progression in any area of our society. However, it is important to look at the big picture. Teeth are important and good dental health greatly increases the quality of life. Just ask the patient I saw last Sunday for an emergency extraction after days of excruciating pain having not been to a dentist in a few years.
Dr. St. Clair maintains a private dental practice in Rowley and Newburyport dedicated to health-centered family dentistry. If there are certain topics you would like to see written about or questions you have please email them to him at jpstclair@dentalhealthforlife.com. You can view all previously written columns at www.dentalhealthforlife.com.
7 Traits of the Ideal Doctor
April 26, 2012
What makes for an ideal doctor? Patients shared their views in a study which appeared in an issue of Mayo Clinic Proceedings. It’s based on nearly 200 patients treated at the Mayo Clinic in Arizona and Minnesota.
In phone interviews with people who had no professional ties with the Mayo Clinic, the patients described their best and worst experiences with their Mayo Clinic doctors, with confidentiality guaranteed. The doctors seen by the patients came from 14 medical specialties.
Who made the list?
Here are the seven traits listed by the patients, along with the patients’ definitions of those traits:
• Confident: “The doctor’s confidence gives me confidence.”
• Empathetic: “The doctor tries to understand what I am feeling and experiencing, physically and emotionally, and communicates that understanding to me.”
• Humane: “The doctor is caring, compassionate, and kind.”
• Personal: “The doctor is interested in me more than just as a patient, interacts with me, and remembers me as an individual.”
• Forthright: “The doctor tells me what I need to know in plain language and in a forthright manner.”
• Respectful: “The doctor takes my input seriously and works with me.”
• Thorough: “The doctor is conscientious and persistent.”
That list isn’t in any particular order. The researchers didn’t check whether confidence was more important to patients than respectful treatment, for instance. The Mayo Foundation funded the study.
The traits covered doctor’s behavior, not technical know-how. That finding “does not suggest that technical skills are less important than personal skills, but it does suggest that the former are more difficult for patients to judge,” the researchers write.
They add that patients may tend to assume that doctors are competent unless they see signs of incompetence, the researchers add.
One patient put it this way in the study: “We want doctors who can empathize and understand our needs as a whole person. We want to feel that our doctors have incredible knowledge in their field. But every doctor needs to know how to apply their knowledge with wisdom and relate to us as plain folks who are capable of understanding our disease and treatment.”
The opposite of those seven traits would be: timid, uncaring, misleading, cold, callous, disrespectful, and hurried. Can healthcare ever be high quality if the patient-doctor interaction is any of these? Technically, the care can be high-quality but is it really a place that you want to be treated?
What Would You Do?
April 16, 2012
The ABC show, “What Would You Do?” with John Quinones, is a reality show using a hidden camera that puts ordinary people on the spot with ethical dilemmas. From bullying to abuse, racial attacks and children using foul language in public, the show is geared towards the reactions of unsuspecting people put in uncomfortable situations.
It is interesting to see how people handle these interactions. Many people step up and engage in the situation and many others step aside with the notion that it is none of their business. Last week I presented an ethical dilemma but this week is about a question I get asked almost daily, “What Would You Do?”
When people come to me with dental problems and I present different options, they often ask me this question. It is difficult sometimes putting myself in other people’s shoes so I use a concept I learned long ago from a mentor which is – Would I Do It On Me? The acronym is the WIDIOM rule.
Most often there are at least a couple of different acceptable ways to handle dental problems. When someone asks what I would do if I was in their situation, I look at it just like that – If that tooth or those teeth were mine, what would I do knowing what I know?
Let’s look at a specific example. A patient comes in with a tooth that has a big problem. The tooth has extensive decay that involves the nerve and extends below the gum line. I explain to the patient that the tooth can be saved with root canal therapy, some minor gum surgery and a crown or the tooth can be extracted and replaced with a dental implant. The other option is to remove the tooth and leave the space. The patient then asks me the question, “What would you do?”
Any of the treatment options above would be an acceptable way to treat this problem. Depending on the circumstances, I may choose any of the treatment options. I may choose to extract the tooth and not replace it if the tooth is not going to impact me functionally or esthetically. If “my” homecare is poor or if “I” do not visit a dentist regularly, I may choose the dental implant option because of long-term predictability.
This is just one example. Patients also frequently ask me about orthodontics, wisdom teeth and certain cosmetic treatments. In my experience, about 75% of the time the patient ends up doing the treatment that I would do. Regardless of their decision, it seems that for those that ask this question, the information helps them in making a decision that is best for their individual circumstances.
As I was working on this column one morning last week the news became flooded with the “controversy” over dental x-rays and their relationship with a type of benign brain tumor. As I listened to the typical distortion the media puts on everything, I started to do some research on the study.
Next week’s column will address this story. I will discuss the facts of the study and how they relate to the typical dental patient. It never hurts to ask your dentist, “What would you do?”
Ethics in Advertising
April 2, 2012
I was listening to the radio on the way home from work the other day and heard an advertisement for a dental office. The ad stated that they were specialists in cosmetic dentistry and implants and that they are the “premier” dental office in the area.
There is no recognized specialty in cosmetic dentistry or implants. Therefore, claiming that you are a specialist for either of these two areas is both illegal and unethical. While it is not illegal to say that you are the “premier” office, it too is unethical for advertising in dentistry.
While I have no problem with legal and ethical advertising in dentistry, what concerns me is over-advertising. The last thing the field of dentistry needs is the public looking at dentists in general as opportunists, and not as dedicated and concerned professionals. How this plays out in the long run will be decided by the ethical standards practiced in dental offices and the rules and regulations enforced by the governing within the profession.
Ethics is about doing good and the concept of right and wrong. Things that may be legal may not be ethical. On the same note, procedures that a dentist is not properly trained in or does not have the technical ability to perform, at least within the standard of care, may be legal for that dentist to do but not ethical. “”Do no harm”, should be the first item on the list of any dentist or any other healthcare provider.
Unfortunately there are healthcare providers, including dentists, who think they are doing people good but don’t realize they practice outside of their true ability. In 1952, the legendary (in the dental world) Dr. L.D. Pankey said, “It’s the moral obligation of the dentist to bring his ability up as close to his capability as possible in accord with his talent. Learning the technique is not enough. A dentist needs to learn how to take care of the whole person.” That is as relevant in 2012 as it was in 1952.
A healthcare professional’s core protocol should be prevention and the quest for determining an individual’s risk for future disease even before the patient has expressed concern. There is a push in dentistry to treat patients based on more objective data, which is commonly referred to as evidence based dentistry. Basically, information about a particular situation is fed into a database containing a multitude of clinical research and “the computer” spits out the best treatment options for that situation based on research. What this does is to minimize the emotionally and empirically based part of the clinical decision making process. My only issue with this is that the empirical, or practical experience of the provider, plays a key role in deciding what is best for a particular patient based on an individual’s unique circumstances.
Cosmetic dentistry poses a different challenge because it is highly discretionary. The dentist, or cosmetic surgeon if we are talking about medicine, must be the patient’s advocate and remain more concerned about the patient’s issues and wellbeing than their own. The benefits of treatment should always outweigh any possible negative consequences. Sometimes the best treatment is no treatment. Sometimes the best treatment for an individual patient is cosmetic enhancement because the benefits of this treatment will have a positive impact on their life.
Any general dentist does “cosmetic” dentistry and most at least do parts of implant procedures. As in any profession, there are varying degrees of talent. Your comfort level with the dentist and the office in general is most important. If you are interested in something that you hear advertised, ask your dentist. He or she probably offers those services.
Lyme Disease and Mercury Fillings
March 26, 2012
I love working outside. Whether it be mowing the lawn or cleaning up brush in the woods, doing outside manual labor is “therapy” for me. However, I have also grown petrified of contracting Lyme disease.
I have seen a steady increase in the number of my patients who say they have contracted Lyme disease. Most of these people said they had the classic “bulls-eye” rash, went on antibiotics for a couple of weeks and were done with it. I have also had other patients who are dealing with long-term issues associated with Lyme disease. Most of the data I found agreed that the success of treating Lyme disease is higher the sooner it is identified and treated. The same data also noted that misdiagnosis of Lyme disease is very high, which often delays treatment.
I think it is pretty safe to say that Lyme disease is bad news. Lyme disease is a multi-system inflammatory disease that affects many of the systems in the body, including the brain. It is most commonly thought to be acquired through the bite of a deer tick that is carrying the dangerous bacteria. However, newer medical evidence shows that the bacteria may also be spread through other means.
Other than the standard antibiotic treatment for Lyme disease, there are also many “alternative” treatments out there. It seems to me that when there are multiple “alternative” treatments to things, where some people show improvement and others do not, the disease itself is not very well understood. I believe this is the case with Lyme disease.
I had a patient recently ask me to review some information about a treatment she is ready to start to battle the symptoms she has from Lyme disease. The process is basically to detoxify the body of heavy metals, including mercury. If you look at stuff on the web about this it brings up the well-known silver/mercury filling debate. Here is an excerpt from one of the websites I found:
“Mercury amalgams are about 55% mercury, and the government makes dentists handle them like nuclear reactor material before it goes into the mouth, and when it comes out of the mouth they have to handle it in the same way, in a bio-hazardous container. But the American Dental Association still tells the dentists and the patients that it’s safe when it’s inside your head. And I think that’s oxymoronic. It doesn’t even make sense.
That means that our heads are considered bio-hazard containers. There’s a device called a mercury vapor analyzer, a device that can be stuck in your mouth after you chew a piece of gum, and it can show you how much mercury is coming off your gum every time you chew. But a lot of people who use that vapor device find that the mercury content in their mouth exceeds the Environmental Protection Agency’s recommendation for safe air.”
There is no published scientific data that I am aware of that shows that removal of silver fillings from your mouth cures anything. Having said that, I have not used the material for over 12 years for basically the same reasons that are described in the quote above.
As far as the Lyme disease issue goes, my recommendation is not to get Lyme disease. It seems that Lyme disease is not well understood. For my patient, and anyone who continues to have symptoms after conventional antibiotic treatment, I guess I would try any alternative treatment that seemed reasonable with little risk.
Special Message To My Patients
March 10, 2012
To my patients…….
My blog posts are usually copies of the columns that write for The Town Common paper weekly. If you don’t read them regularly take a look at some of the posts below and see if the subject matter interests you. Pass them on to your friends and family…..or have them like my facebook page.
Dental decay is still a major problem in our society. Decay rates can change over time from dietary changes, medication changes, and gum recession to name a few. Existing fillings or crowns are not protection against decay. Understanding and improving your diet, improving your home care and maintaining professional care are things we can all work on. As I have said before….Decay is a bacterial and pH (acid) disease that I believe is 100% controllable.
One product that I have written about before and talked to many of you about is Xylitol. Xylitol is a sweetner that is also anti-cavity. It can be found in hard candies and gum manufactured by only a few companies.
I recently ordered samples of peppermint candies, fruit lollipops and gum with Xylitol. If you are interested in trying them out to see if you like them, please stop by the office. If you like them I can order them for you. The recommended “dose/day” is 3-5 servings for helping prevent cavities. The thing to look for is to determine if you like the taste of Xylitol and whether it bothers your stomach.
One more important note on Xyitol……it is poisonous to dogs…..not sure why….xylitol is a sugar alcohol…..but it is harmful to dogs so please be aware of that.
Also, I have put many of you on a prescription fluoride toothpaste if I felt you were more susceptible to decay. Although I am NOT a proponent of water fluoridation, I have seen the benefits of topical fluoride. If you are not on this and wonder if you should be, please just ask us.
I believe that most people do not need xylitol or fluoride (or at least additional fluoride) to prevent decay. I think that diet can control most of the decay problems I see. However, change is sometimes difficult for people. Things like xylitol and fluoride are beneficial for people where diet alone cannot change their decay risk.
Thank you for trusting us to work with you to achieve and maintain better health.
Peter St Clair
Holistic Dentistry
March 9, 2012
For whatever reason, I have had a group of patients migrate to my office from a “holistic” dental practice in a different part of the state. The Merriam-Webster dictionary definition of “holistic” is –“relating to or concerned with wholes or with complete systems rather than with the analysis of, treatment of, or dissection into parts. Holistic medicine attempts to treat both the mind and the body.”
Most of us are probably more familiar with the term “holistic” in the medical world than in the dental world. I have done a little research on “holistic dentistry”, and to be honest, I have a lot more research to do. In the future, I plan on writing more about my research on this subject.
I make most of my clinical decisions in practice based on peer-reviewed, published scientific evidence. I like facts. However, I am also an avid student of the psychological and emotional side of what I do. My initial research into “holistic” dentistry has found both things that I am attracted to as well as borderline quackery.
For the purposes of the column this week, I am going to comment on the Holistic Dental Association’s philosophy taken from their website. I have commented on each individual paragraph below:
We believe that Holistic involves an awareness of dental care as it relates to the entire person.
Most people are now well aware that the mouth and the rest of the body are connected. We know that there are connections between dental health and systemic health as it relates to things such as heart disease. The holistic approach seems to go beyond this.
We believe that health care practitioners and recipients should be provided with appropriate information to make informed choices that will enhance personal health and wellness while feeling loved, accepted, and understood.
Much of the “holistic” approach is a frame of mind. Different people need different amounts of information to make an informed decision for their particular situation. It is the communication and relationship between the patient and the doctor that is most important.
We believe that Holistic Dental Association membership provides physical, emotional, and spiritual support while we expand our awareness and skills.
No comment.
We believe our educational growth should be nurturing, affordable, and encompasses basic information, experiential knowledge, and leading edge ideas.
Experiential knowledge means knowledge gained from direct experience. I would agree that many of the things we do are based on our own experiences and often that information can benefit someone else. However, I do not see anything in this statement that relates to published scientific data.
We believe in openly sharing resources. We believe in an inter-disciplinary approach to health that facilitates the individual’s innate ability to heal her/himself.
Most organizations, when it comes to learning, are open to sharing resources. Most practitioners use an inter-disciplinary approach to provide what they feel is best for the patients. The last part of the statement is the more “holistic” part.
I will share more about specifics in “holistic” dentistry in the future.
The Survey Results Are In
March 1, 2012
A few weeks ago I posted a survey on my office Facebook page that I mentioned in this column. The question was – If someone offered you $1 million, would you allow all of your teeth to be removed? If you haven’t taken the survey and would like to, please go to the Facebook page listed at the end of this column. If the numbers change on this survey I will report them at a later date. For now, here are the results:
75% of respondents were female
12% are missing more than 2 teeth not including their wisdom teeth
75% of respondents consider themselves dentally healthy while the other 25% consider themselves “sort of” healthy
62% visit a dentist every 6 months
100% would not take the $1 million to have all of their teeth removed.
Although there was not one person who would allow all of their teeth to be removed, let’s look at who took this survey. First, it appears that most respondents were readers of this paper and probably frequent readers of this column. I would make a blanket statement that frequent readers of this column put their health relatively high on their priority list.
However, only 62% visit a dentist at least every 6 months. The national average is around 50%. It does surprise me that only 62% of those who are “more dentally educated” see a dentist at least every 6 months.
When I am quick enough to use them, I like to use analogies. I analogize with cars frequently. Teeth and cars are two things that we use daily and often take for granted until something goes wrong. Would you drive your car until something happened without ever changing the oil? What could possibly happen if you did that? It would probably mean catastrophe. You would probably be told that the car is junk and you need a new one or it would be very expensive to fix.
I see the same thing the mechanic sees. Failure to perform routine maintenance will lead to problems. The extent of the problems will depend on factors such as how well the car was built, how often it is used and/or abused, and how well YOU take care of it. Those who take meticulous care of their car and get regular routine maintenance will keep their car much longer and have many fewer problems along the way.
I was also a little surprised that no one would take the million for their teeth. For $1 million you could have as many dental implants as you wanted to replace the teeth and still have plenty of money left over. However, it is a long road that apparently no one is willing to go through.
In case you were wondering what my answer to the question would be, here it is. As a dentist, knowing what would be involved to take a dentally healthy person’s teeth out, I would also not take the million. The physical, and more importantly emotional toll that this would put on me is hard to put a price on.
We all take too many things that we rely on daily for granted. Think about the things in life that are important to you. Think about what it would mean in your life if they weren’t there. The moral of the story – take meticulous care of the things that are important in your life.
Wanna Be a Dentist?
February 15, 2012
I’m sure you have heard that dentists are always at the top of the list for suicide, divorce, and substance abuse. I did a little research just to verify that is actually accurate…..and yup, it is. I could go into why I think that is the case, but I’ll let you ponder that one on your own.
Despite the many challenges of this profession, if I could do it all over again, I would still choose to be a dentist. I didn’t decide to go to dental school until late in my senior year of college. People ask me all the time, “What in the world made you decide to look inside of mouths every day?” Believe me, I asked myself the same question when I decided to apply to dental school. It was a last minute decision.
Today, I am glad I went into a profession that allows me to problem solve and can be both easy and challenging. I guess it is my approach. I see myself as an educator and a health care provider who wants to help people decide to what level of health they wish to achieve. I have also made the conscious choice to enjoy what I do every day. When things occur that I do not enjoy, I try not to focus on the negative. It is always a work in progress.
For a dentist, and for that matter anyone in any profession to be successful, they must know themselves and have standards they are able to communicate with passion and energy. One thing is very clear, behavior, with its impending results, is a choice. We make choices every minute of every day. What we choose to do with the paths presented to us is a choice. Being frustrated with your job, trying to copy others instead of discovering yourself as well as dental care is a choice.
All dental care is elective. There is nothing that you have to do. That is what makes this profession the most fun and rewarding for me. A dentist who worries about how much of a particular procedure they do, or tries to sell dentistry as a commodity will become frustrated. That is why there tends to be a high burn-out rate in this profession. It should be about education. It should be about people and caring about their health.
It is also about building trust with people. If any of my patients out there ever had a thought that I was trying to “sell” them something, there is an issue with trust there. I use the car analogy often. First, you decide that you are buying a car. It is only after you decide that you are buying a car that you pick the style, the brand, and the options. It is with that information that you make a decision on what car you are buying, based on what you want and feel is right for you. I look at dentistry the same way.
Dentistry combines health care, artistry, psychology and business all into one. As in any job, there are good times and not so good times. There is always room for improvement in all aspects of the profession and the options for continuing education to improve are limitless.
If you, or if you have kids in high school or college who are wondering about what to do with their life, introduce the possibility of a career in dentistry. Ask your dentist if they would talk to you or them about the profession or even do mentorship. It’s a wonderful profession.
What Your Mouth Says
February 2, 2012
A few weeks ago there was a large article in The Wall Street Journal entitled, “If Your Teeth Could Talk.” It was a basic review of some of the connections between oral and systemic health and also offered some newer research that I was unaware of.
I have written many times on the growing evidence linking periodontal (gum) disease with many systemic issues. The fact of the matter is the mouth is truly the gateway to the rest of the body. While some early signs of diabetes, cancer, pregnancy, immune disorders, hormone imbalance and drug issues can show up in the mouth long before the person discovers that there is a “problem”, an unhealthy mouth also puts you at greater risk for things like heart disease, stroke, diabetes, and pregnancy complications.
A study done at New York University in 2009 reported that 93% of people who have periodontal disease are at risk for diabetes. The issue is inflammation and the fact that periodontal disease and diabetes exacerbate each other. Inflammation from periodontal disease, a chronic non-symptomatic disease, makes it more difficult for people with diabetes to control blood sugar levels. High blood sugar accelerates tooth decay and gum disease, which elevates inflammation. It is a vicious cycle.
However, more recent studies show that treating gum disease improves circulation, reduces inflammation and can even reduce the need for insulin in people with diabetes. The estimates are that six million Americans have diabetes and don’t know it. The risk of not treating either disease can have irreversible consequences.
If you have ever had a planned surgery you probably were asked about your dental health, how often you visit a dentist and asked to get “clearance” from your dentist prior to surgery. The reason for that is because the type and quantity of bacteria present in uncontrolled gum disease is much higher than in periodontally healthy individuals. Bacteria from the mouth can travel through the bloodstream and cause problems elsewhere. Far too often patients come to me a month before surgery and say they need to get their mouth in shape prior to their procedure….an often impossible task.
There are also an increasing number of people on medication and the number of medications they are taking. Many drugs, including but not limited to blood thinners, bisphosphonates (ex. Fosamax), blood pressure medications, antidepressants and chemotherapy drugs can all have effects on the mouth that can be devastating if not closely monitored.
This is all “real” stuff. I deal with these issues in the office every day. I use this analogy a lot, “Periodontal disease is like diabetes, it is not curable, but in most cases it is controllable.” For most patients, good home care combined with good professional care can control this disease. Just as in the lottery, “you can’t win if you don’t play”. However, the consequences for not playing the dental game are more risky.
If you didn’t take the survey last week that I discussed, go to the Facebook page below to take it. I will be reporting the results in the next couple of weeks. So far, not one respondent would give up their teeth for a million dollars. Would you?
