During my presentation last Friday I showed the group a radiograph with a class two lesion and asked them to choose “Fill it or Watch It?” It’s a fun exercise to experience the thought process behind clinical treatment recommendations. After the program, taking the escalator down to the lobby, Dr. Gary DeWood and I were reflecting on the program and he made a comment that stopped me in my tracks. “ I hate when dentists say they are “watching” something. What are we “watching” it do? I don’t want my physician “watching” my heart disease.” I realized how something I have been saying for more than two decades must sound so peculiar to my patients, and doesn’t fit with my philosophy of practice at all. What would I think as a patient when the dentist or hygienist tells me I have a “small cavity, but we are just going to watch it”? I can think of a whole list of things that would go through my head, and most of them do not reflect positively on us as a practice.
Just before we closed the office for the holiday last week I had a patient come in suffering from a dry socket. In the name of full disclosure I must confess I haven’t done an extraction in over a decade. My patients however, do have them done and some experience the sequelae of a dry socket. The tooth had been extracted a few days earlier, and the specialist had packed the dry socket twice before leaving to see family for Thanksgiving. The patient reported the packing had relieved the discomfort, but the relief only lasted about twenty-four hours before the pain returned.
Whether we are working to polish natural teeth after completing an occlusal adjustment or placing a restoration acquiring the final polish is critical. One of the first things a patient will do is explore what has been done in their mouths. I am amused as they feel around in their own mouths with their tongue, other teeth and sometimes fingers. After watching this for so many years, in an attempt to take some of the discomfort out of it, I invite my patients to engage in this part as we sit them up. As we hand them a mirror we ask for their final seal of approval before the appointment has ended, “take a look for us and make sure to feel around your mouth with your tongue to make sure things feel smooth. You also may want to check your bite one last time. If you find anything that doesn’t feel right please let us know.”
This Thanksgiving weekend I am in New York, and today I am speaking at The Greater New York Dental Meeting. Dental Education has been a critical component of my professional and personal life. I know that staying engaged depends on learning for me, and I think this is common amongst dental professionals. In addition to my own learning I spend a good deal of time putting courses together and designing programs that will be beneficial for others. To help me do this more effectively I would love to know your preferences around topics and program logistics. If you follow the link below it will take you to a simple ten question survey that should only take a moment or two to complete. The information is invaluable as I plan for the future, so Thank You for responding. The Survey will open in a new page.
Here in the US we are celebrating Thanksgiving today. For me this is a day of family, friends and giving thanks for all of the many things in my life I am grateful for. This year will be very different, and yet those same things will be present. For the first time ever instead of being home and cooking we are headed off to New York. So today we are having Thanksgiving dinner in Manhattan at “The View” restaurant at the top of the Marriott Marquis. We will still have far more food than we can possibly eat, including turkey, mashed potatoes and apple pie. My whole family is together, and we are also with our dear friends the DeWoods ( Gary, Cheryl Tricia, Dale and Katie) and the Carstensens ( Steve and Midge) making an incredible memory.
As always it is a day to reflect on the things I am thankful for, and there are so many. I will take some time alone to reflect and I will also reach out to many very special people in my life and say thank you. If you are celebrating today have a fabulous holiday!!!
With the holiday weekend for Thanksgiving starting tomorrow I thought it was perfect timing to share a trick I just learned recently from a dear friend. One of the things that I know is likely to happen over a long weekend or holiday is a few emergency phone calls from patients new and old. A handful of these may be due to a permanent or temporary crown coming loose. Over the years that I have been in practice I have tried suggesting a variety of ways my patients can manage this on their own. In my experience the temporary cements that they sell over the counter in drugstores are difficult for patients to use, and normally result in a mess for both the patient and I. Somewhere once I heard to have them use Vaseline as a temp cement, and I have had poor results with this approach. Other things I have heard is to use toothpaste which I never personally recommended as I was worried that it would cause sensitivity against the dentin.
It is common for patients to present with what dental professionals would call a “gummy” smile. This appearance of excessive gingiva above the cervical of the maxillary anterior teeth in a full smile can have multiple causes, one of which is the diagnosis hypermobile lip. When we think about excessive gingival display, the first thing to remember is that not everyone finds this unattractive. Many of my patients show a significant amount of gingiva at a full smile and find it very pleasing esthetically. Commonly when there is more than 3-4mm of gingival display we and our patients will find this as an esthetic issue, but I remember to bring this conversation up gently so as not to offend someone who isn’t bothered by it.
Last Friday I presented a webinar entitled “Minimizing Adhesive Failures”. When we think about how adhesive failures show up in our clinical practices we see open or leaking margins, recurrent decay, staining or perhaps the most severe is the loss of a restoration due to ineffective bonding. There are many common easy to overcome technique challenges that contribute to these clinical failures. One that I wanted to get the participants to think about was including retention form and resistance form in our preparations for bonded restorations. It is become more of a trend to rely exclusively on the micro-mechanical and chemical adhesion of dentin adhesives, and completely eliminate the macro-mechanical features of the preparation. Before the advent of adhesive dentistry retaining a restoration was dependent entirely on the features of the prep. So now that we have the ability to “bond” do we need retention form?
I answered an e-mail this evening about resin bonded bridges to replace maxillary lateral incisors. The patient is a 15 year old with congenitally missing laterals and the question is what to do in the interim to hold space, correct the esthetics, and create a situation where the patient can be comfortable and confident until she is older and can consider implant placement. Resin bonded bridges can be a great restorative option for young people as an medium term solution. The original design of resin bonded bridges required the preparation of the lingual of the abutment teeth and the framework was made from cast metal. The challenge of this classic design is that you can often see the shadowing behind the retainer tooth from the metal and at the connectors. Another more modern alternative I hear discussed is Zirconia. This approach has two major issues, one of which is the connector size, and it very rarely looks good or works with laterals. Both metal and zirconia have to be cemented as they can not be truly “bonded” for retention, which means you need some sort of prep and need to have light to no occlusion on the bridge. Even with this when you look at the research the classic de-bond of these bridges is between the restoration and the resin cement, not a failure of the bond to enamel.
Tooth Whitening has been a regular part of dental practice for long enough that we can loose some perspective on the valuable role it plays. In a recent blog post by Gary Takacs he quoted a USA Today survey that showed 85% of the respondents wanted whiter teeth. My day to day experience aligns with this, as the most common esthetic treatment my patients ask for is whitening. Providing whitening in my office is a valuable service on multiple levels. First I am providing a service that my patients want, increases their confidence and makes them feel better about themselves. Whitening is a safe, comfortable way to begin a conversation with patients about esthetics and the appearance of their teeth. In my experience many of my patients struggle with not wanting to appear vain or not certain what their options are for altering how their teeth look. Whitening has become a daily part of our interactions, is highly accepted and as a starting place often launches a more extensive discussion of the options in esthetic dentistry.