All future posts for this blog can be found at:
Austin Dentist Blog
https://www.mcfarlanedental.com/blog/
Sincerely,
Dr. Russell McFarlane
Tuesday, December 25, 2012
Friday, December 7, 2012
Tuesday, November 27, 2012
Teething: Your baby is in real pain. Wisdom teeth: adult teething
Teething: the movement of a tooth through the gums, whereby the root grows as the tooth moves into place.
Big picture
Baby teeth:
Whether it is baby teeth coming into the mouth, or adult teeth replacing baby teeth, the process of eruption can be very painful. Get the baby Tylenol® ready, because the screaming and crying is a response to the actual perception of tissue destruction. Before the teeth pierce the gingiva, they apply pressure to the tissue, which causes redness and soreness of the gums. The desire to chew sharp objects is your child's natural response to help "cut their teeth." What they are actually cutting is the thick inflamed gingival tissue.Adult teeth:
Adults who start having this pain frequently come to the office for emergency visits. Wait!!! Adults have teeth coming in. Anywhere from ~18-28-yrs-old is about the time that wisdom teeth like to start coming in. This frequently causes severe pain, especially since there is frequently not enough room for them and they like to try and erupt into impossible positions putting all the adjacent teeth and tissues in pain.
More Specifically
Baby teeth:
I really feel for my baby. She is one. Last night she really let me have it because she is having severe teething pain. So, I gave her a frozen plastic ring with small poking parts on it designed for the specific purpose of helping with this discomfort. After about a half hour of chewing on this and a weight appropriate microdose of baby Advil (1 tsp), she was finally able to relax and fall back asleep.Adult teeth:
I sometimes see adults come in with similar amounts of pain as it relates to their partially-erupted soft-tissue impacted wisdom teeth (also called: 3rd molars). What is frequently problematic about these partially-erupted wisdom teeth is that they cannot come in all the way because they are blocked out (impacted) due to their position as it relates to their 2nd molars, and a tissue flap sits over 90% of the top of the tooth and often a bit of bone as well. Why does this matter? Food packs into this uncleanseable space and then it sits their in the presence of oral bacteria and it ferments and becomes infected (fancy term: Pericoronitis). Then, the patient presents with pain, purulent drainage, and needs emergency care of their wisdom teeth.A Diagnostic Plan
Baby teeth:
Plan on giving your baby or child appropriate medication and tools to help with normal eruption. One rule of thumb to see if things are moving in the right direction - teeth should come in sets of two, parallel as in a mirror image from the midline of the central teeth.Adult teeth:
You may be a person who thinks, "Oh, no not me." "My wisdom teeth are not a problem." "I have lots of space for them to come in." Let me give you a dentist's perspective on this attitude. Even if you have room for them, you will not heal as easily when they have to be extracted in your old age. Let's assume you live to a ripe old age of 80 and your dexterity is still good - even these people tend to miss their wisdom teeth when brushing and flossing. Wisdom teeth are wont to get cavities and periodontal disease. Planning to have them removed before they become a serious problem is still a prudent choice, for the person who wants to avoid the pain and problems that you can expect with wisdom teeth.Tuesday, October 30, 2012
What do you do with the old crowns?
Patients frequently have curious questions that they feel uncomfortable asking, but a few brave souls will ask.
Here is one of those questions.
What do you do with old crowns you cut off?
I have a great answer. When we cut off a crown at McFarlane Dental, patients have two options.
Option 1: They can leave it with us. We save those crown fragments until we have collected several pieces. I then send those crown pieces off to a refiner. I take the staff out to a nice dinner. I always thank patients in advance when they decide to leave old crown fragments behind, letting them know that they are taking the staff out to dinner. We recently went to Kona Grill in the domain celebrating my wonderful and caring staff. We even had dessert. ;)
Option 2: They can keep the piece. I will give them a kit that they can use to send the piece in and refine it for themselves.
Thanks to all the patients who have made it possible for me to take the staff out to a nice dinner. We had a great time, building relationships. Strong staff relationships make for smooth appointments and good office communication.
The follow-up question many patients ask is:
They have gold in them. Isn't that worth a lot?
Truth be told, the majority of the cost of the crown is the labor of preparing the tooth, making the impression, and seating the crown. The lab fee for the crown includes: i. the cost of the metal, and ii. the labor our lab puts into the work of making the crown. We use a local Austin Dental Laboratory (http://www.serettidentallab.com/) and use only the highest quality materials. Each crown that we cut off has ~$10 of precious metal in it. The most common crowns that we cut off and replace due to decay or fracture are porecelain-fused-to-high-noble-metal crowns. This type of crown has less refining value because most of their mass is from the porcelain stacked on the outside of the metal shell. A full-cast-high-noble gold crown might have somewhere between $25-$45 of precious metal in it, depending on the thickness of the actual crown. To take my entire staff to dinner at a nice restaurant to reward them for their hard work, we save approximately 30 old crowns, which have usually been sectioned into two pieces.
Many of our patients enjoy knowing that they are doing something nice for the staff by leaving that crown fragment behind. This strategy for the use of the old crowns, generally pleases all parties. My staff looks forward to going out because they know we will go somewhere exquisite. I get to enjoy time with my staff that does not have the normal rigidity of work. My patients get the pleasure of knowing that they are doing something nice for our staff with a crown fragment, which had they kept it, likely would have ended up in the trash.
Here is one of those questions.
What do you do with old crowns you cut off?
I have a great answer. When we cut off a crown at McFarlane Dental, patients have two options.
Option 1: They can leave it with us. We save those crown fragments until we have collected several pieces. I then send those crown pieces off to a refiner. I take the staff out to a nice dinner. I always thank patients in advance when they decide to leave old crown fragments behind, letting them know that they are taking the staff out to dinner. We recently went to Kona Grill in the domain celebrating my wonderful and caring staff. We even had dessert. ;)
Option 2: They can keep the piece. I will give them a kit that they can use to send the piece in and refine it for themselves.
Thanks to all the patients who have made it possible for me to take the staff out to a nice dinner. We had a great time, building relationships. Strong staff relationships make for smooth appointments and good office communication.
The follow-up question many patients ask is:
They have gold in them. Isn't that worth a lot?
Truth be told, the majority of the cost of the crown is the labor of preparing the tooth, making the impression, and seating the crown. The lab fee for the crown includes: i. the cost of the metal, and ii. the labor our lab puts into the work of making the crown. We use a local Austin Dental Laboratory (http://www.serettidentallab.com/) and use only the highest quality materials. Each crown that we cut off has ~$10 of precious metal in it. The most common crowns that we cut off and replace due to decay or fracture are porecelain-fused-to-high-noble-metal crowns. This type of crown has less refining value because most of their mass is from the porcelain stacked on the outside of the metal shell. A full-cast-high-noble gold crown might have somewhere between $25-$45 of precious metal in it, depending on the thickness of the actual crown. To take my entire staff to dinner at a nice restaurant to reward them for their hard work, we save approximately 30 old crowns, which have usually been sectioned into two pieces.
Many of our patients enjoy knowing that they are doing something nice for the staff by leaving that crown fragment behind. This strategy for the use of the old crowns, generally pleases all parties. My staff looks forward to going out because they know we will go somewhere exquisite. I get to enjoy time with my staff that does not have the normal rigidity of work. My patients get the pleasure of knowing that they are doing something nice for our staff with a crown fragment, which had they kept it, likely would have ended up in the trash.
Friday, October 19, 2012
What do the words "let's watch that spot for a while" mean?
Watch it vs. Treat it.
Let's talk about the difference between being conservative with treatment and being disregardful. It is important that we distinguish between actively tracking a problem with a set end-point (conservatively treating once a specific threshold has been reached) vs. arbitrarily looking at a tooth and not treating it because it is "not big enough yet". The first description matches that of the modern prudent dentist, whom has a clear idea of when the treatment should begin, based primarily on objective findings (e.g. cavity depth shown on X-ray or visible findings) mitigated only by risk levels determined by etiological factors (e.g. home care - brushing/flossing, sugar intake frequency). The problem with the ill-defined "not big enough yet" dentist is the lack of parameters to determine when treatment will begin. Those parameters should be put in place and understood mutually by dentist and patient to prevent catastrophic tooth breakdown and/or infection and/or worsening of the condition (particularly in the case of periodontal disease).
Let's address periodontal disease for a moment. Historically, general dental practices have had a difficult time explaining this disease (severe gum disease) because of the complexity of the disease and the problem that it develops very gradually. If this is a new patient, it is part of our comprehensive assessment to determine the risk levels for 1. periodontal (gum) health 2. caries (cavities) risk 3. bruxism functional (grinding) risk 4. cosmetic assessment. Every exam includes a head and neck cancer screening. When an existing patient has a cleaning we check those probing depths at least once a year to reevaluate their depth. When a patient begins having 5 or 6mm pockets in an area, we don't just watch it. We address it while it is still manageable. Thirty years ago, these patients might have had to wait until they had several sites of 6mm with bleeding and pus to receive any treatment at which time they would be referred to the periodontist for gum surgery. Now, we scale those areas under local anesthetic, and we have been having incredible success with localized laser treatment to these areas, which heals quickly and eliminates the ulcerated and infected pockets.
So, whether it is watching a cavity grow bigger or gum pockets get deeper or TMJD become more severe or teeth shift further out of alignment, there are interventions that are frequently cheaper, less painful, and more effective when the problems are treated while the problems are still small. I tell my staff if we are going to watch something we must have a specific criteria that determines when we will move on and recommend treatment. Otherwise, "watch it..." really means “WATCH IT GET WORSE".
We have a little saying that "watch it" is not a complete sentence. The full sentence is "watch[ing] it get worse".
Please note: there are cavities that are so small that they can be remineralized with a high fluoride toothpaste. Likewise, patients can stabilize and learn to maintain a 5mm pocket. Some clicking of the TMJ is harmless and (if painless) is still only a low risk factor.
The point of this entry is not to say that every tiny thing must have some immediate treatment, but rather to say that treatment often offers the best hope of minimally-invasive, successful, comfortable care. Furthermore, this blog entry is suggesting that it is in a patient's best interest to know if we are "watching a spot," when will we know it's time to decide to treat. Not treating small cavities and early periodontal disease is not always the most conservative form of treatment, since more advanced stages of these diseases often require more advanced forms of therapy.
Let's talk about the difference between being conservative with treatment and being disregardful. It is important that we distinguish between actively tracking a problem with a set end-point (conservatively treating once a specific threshold has been reached) vs. arbitrarily looking at a tooth and not treating it because it is "not big enough yet". The first description matches that of the modern prudent dentist, whom has a clear idea of when the treatment should begin, based primarily on objective findings (e.g. cavity depth shown on X-ray or visible findings) mitigated only by risk levels determined by etiological factors (e.g. home care - brushing/flossing, sugar intake frequency). The problem with the ill-defined "not big enough yet" dentist is the lack of parameters to determine when treatment will begin. Those parameters should be put in place and understood mutually by dentist and patient to prevent catastrophic tooth breakdown and/or infection and/or worsening of the condition (particularly in the case of periodontal disease).
Let's address periodontal disease for a moment. Historically, general dental practices have had a difficult time explaining this disease (severe gum disease) because of the complexity of the disease and the problem that it develops very gradually. If this is a new patient, it is part of our comprehensive assessment to determine the risk levels for 1. periodontal (gum) health 2. caries (cavities) risk 3. bruxism functional (grinding) risk 4. cosmetic assessment. Every exam includes a head and neck cancer screening. When an existing patient has a cleaning we check those probing depths at least once a year to reevaluate their depth. When a patient begins having 5 or 6mm pockets in an area, we don't just watch it. We address it while it is still manageable. Thirty years ago, these patients might have had to wait until they had several sites of 6mm with bleeding and pus to receive any treatment at which time they would be referred to the periodontist for gum surgery. Now, we scale those areas under local anesthetic, and we have been having incredible success with localized laser treatment to these areas, which heals quickly and eliminates the ulcerated and infected pockets.
So, whether it is watching a cavity grow bigger or gum pockets get deeper or TMJD become more severe or teeth shift further out of alignment, there are interventions that are frequently cheaper, less painful, and more effective when the problems are treated while the problems are still small. I tell my staff if we are going to watch something we must have a specific criteria that determines when we will move on and recommend treatment. Otherwise, "watch it..." really means “WATCH IT GET WORSE".
We have a little saying that "watch it" is not a complete sentence. The full sentence is "watch[ing] it get worse".
Please note: there are cavities that are so small that they can be remineralized with a high fluoride toothpaste. Likewise, patients can stabilize and learn to maintain a 5mm pocket. Some clicking of the TMJ is harmless and (if painless) is still only a low risk factor.
The point of this entry is not to say that every tiny thing must have some immediate treatment, but rather to say that treatment often offers the best hope of minimally-invasive, successful, comfortable care. Furthermore, this blog entry is suggesting that it is in a patient's best interest to know if we are "watching a spot," when will we know it's time to decide to treat. Not treating small cavities and early periodontal disease is not always the most conservative form of treatment, since more advanced stages of these diseases often require more advanced forms of therapy.
Friday, October 12, 2012
Sedation Dentistry
I have been hearing sedation dentistry advertised to death by dentists lately. So, I think it is time to address this emerging phenomenon. Let's answer 3 key questions: 1. What are the various levels and methods of sedation? 2. Who needs/wants sedation? 3. Why are dentists advertising general anesthesia?
1. There are varying levels of sedation. Local anesthesia blocks action potentials in nerve fibers so that pain cannot be felt during treatment. Dentists typically use amide anesthetics (e.g. 2% Lidocaine with 1/100,000 epinephrine, 4% Articaine with 1/100,000 epinephrine). These are effective at blocking pain for most procedures including root canals and extractions, except when an infection is present. Nitrous oxide is a form of inhaled anesthesia effective for reducing anxiety in patients with minimal anxiety. It gives patients a sense of euphoria, setting in quickly and dissipating quickly with the administration of pure oxygen. For moderate anxiety, orally-administered conscious sedation is an effective tool for reducing anxiety in patients, who might otherwise avoid dental work. Agents frequently used for conscious sedation are midazolam, diazepam, and triazolam (all members of the benzodiapine family). These drugs can be administered safely for a wide range of patients, and the patient stays awake, reducing the risk of oxygen desaturation when properly monitored with NIBP (non-invasive blood pressure) and pulse oximetry. The key to conscious sedation is that you are able to maintain your own airway. IV sedation is a drug delivery method; it can be used to take a person into a state of conscious sedation or deeper into general anesthesia. General anesthesia is used for patients who are severely anxious, and who otherwise could not tolerate dentistry. It is most appropriate for cases where a person cannot tolerate the procedure (e.g. wisdom teeth removal when the patient does not want to feel anything).
At McFarlane Dental, we offer local anesthesia, nitrous oxide, and conscious sedation to improve patient comfort and procedural success.
2. Sedation benefits anxious patients by helping them get the care they need and want without the looming sense of doubt and concern that might otherwise paralyze them from moving forward.
3. I saw an ad by a dentist advertising the slogan, "You sleep while I work." So, from the methods described above, the only reasonable conclusion I could draw is that he or she is promoting the idea that general anesthesia is the go-to solution for dentistry. A 1: 200,000 mortality rate (associated with general anesthesia) is low, but not zero. I would like to try conscious sedation on those patients before turning straight to general anesthesia. If you have been put under general anesthesia for other surgeries, then you know that a medically induced coma is not akin to a good night's rest. I think given the risk to reward ratio, you will see other medical practices adopt the middle road of conscious sedation. [This pubmed article shows that this shift in thinking is already underway.] For most patients, effective local anesthetic that completely blocks pain is enough. For many patients, they need from medication to undergo a dental procedure. For some patients, they need general anesthetia, but conscious sedation is the gold standard to try first.
1. There are varying levels of sedation. Local anesthesia blocks action potentials in nerve fibers so that pain cannot be felt during treatment. Dentists typically use amide anesthetics (e.g. 2% Lidocaine with 1/100,000 epinephrine, 4% Articaine with 1/100,000 epinephrine). These are effective at blocking pain for most procedures including root canals and extractions, except when an infection is present. Nitrous oxide is a form of inhaled anesthesia effective for reducing anxiety in patients with minimal anxiety. It gives patients a sense of euphoria, setting in quickly and dissipating quickly with the administration of pure oxygen. For moderate anxiety, orally-administered conscious sedation is an effective tool for reducing anxiety in patients, who might otherwise avoid dental work. Agents frequently used for conscious sedation are midazolam, diazepam, and triazolam (all members of the benzodiapine family). These drugs can be administered safely for a wide range of patients, and the patient stays awake, reducing the risk of oxygen desaturation when properly monitored with NIBP (non-invasive blood pressure) and pulse oximetry. The key to conscious sedation is that you are able to maintain your own airway. IV sedation is a drug delivery method; it can be used to take a person into a state of conscious sedation or deeper into general anesthesia. General anesthesia is used for patients who are severely anxious, and who otherwise could not tolerate dentistry. It is most appropriate for cases where a person cannot tolerate the procedure (e.g. wisdom teeth removal when the patient does not want to feel anything).
At McFarlane Dental, we offer local anesthesia, nitrous oxide, and conscious sedation to improve patient comfort and procedural success.
2. Sedation benefits anxious patients by helping them get the care they need and want without the looming sense of doubt and concern that might otherwise paralyze them from moving forward.
3. I saw an ad by a dentist advertising the slogan, "You sleep while I work." So, from the methods described above, the only reasonable conclusion I could draw is that he or she is promoting the idea that general anesthesia is the go-to solution for dentistry. A 1: 200,000 mortality rate (associated with general anesthesia) is low, but not zero. I would like to try conscious sedation on those patients before turning straight to general anesthesia. If you have been put under general anesthesia for other surgeries, then you know that a medically induced coma is not akin to a good night's rest. I think given the risk to reward ratio, you will see other medical practices adopt the middle road of conscious sedation. [This pubmed article shows that this shift in thinking is already underway.] For most patients, effective local anesthetic that completely blocks pain is enough. For many patients, they need from medication to undergo a dental procedure. For some patients, they need general anesthetia, but conscious sedation is the gold standard to try first.
Monday, October 8, 2012
Dentistry as Service
When I think about how grateful I am to have dentistry as a part of my life. I think about service to others. Dentistry offers incredible value. When people shrink the value of dentistry, by commoditizing it - separating the procedures from their health improving qualities, and distill it down to money for a filling or money for a crown, it is still an awesome value. A lot of dentistry lasts longer than most luxury commodity items. Let's take crowns for example. If you spent about $1200 on an elite plasma television ten years ago, it may still be working or you may have already replaced it. If you rolled $1300 into a new car purchase ten years ago, that car probably still has some value, but it also probably has 100,000 miles on it and the remaining life span of that vehicle is questionable. The average lifespan for a crown is somewhere on the order of 25-30 years, assuming that you choose a gold crown or a porcelain-fused-to-metal crown.
The other form of service that is uniquely suited to dentistry is Christian mission work. When you donate dental care to patients who might otherwise go without it, their hearts are opened. I have had opportunities to donate care in Matamoros, Mexico, Tegucigalpa, Honduras, Dallas, Taylor, San Antonio, Leander, Round Rock, and I am looking forward to more opportunities. When patients realize how much of yourself you put into your work and say thank you, that is a great reward in and of itself.
The other form of service that is uniquely suited to dentistry is Christian mission work. When you donate dental care to patients who might otherwise go without it, their hearts are opened. I have had opportunities to donate care in Matamoros, Mexico, Tegucigalpa, Honduras, Dallas, Taylor, San Antonio, Leander, Round Rock, and I am looking forward to more opportunities. When patients realize how much of yourself you put into your work and say thank you, that is a great reward in and of itself.
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