Antibiotics For Prosthetic Joints
Q: "I had a hip replacement about a year ago, and my dentist refused to clean my teeth because I had not taken an antibiotic before I came in. Nobody has ever mentioned this to me before, and I think that if I needed it, my orthopedic surgeon would have told me so. What is your opinion?"

A: I compliment your dentist for doing a thorough health history review, as it made him aware of your hip replacement. According to guidelines set forth by the American Orthopedic Society, you should be pre-medicated with an antibiotic. Current guidelines state that any patient who has a prosthetic joint requires antibiotic prophylaxis for a minimum period of two years following the surgery. Depending on the situation, some orthopedic surgeons are requesting prophylaxis for a longer period of time. Similar guidelines are observed for patients with leaky heart valves.

What many patients don't realize is that their gums not only help support and surround the teeth, but they also act as a barrier of defense between the oral cavity and the bloodstream. The oral cavity is teaming with all types of microorganisms. When these bacteria are released into the bloodstream, they can be carried to another part of the body and initiate an infection. If your newly placed prosthetic hip became infected, it could jeopardize its continued healing. By taking an antibiotic one hour prior to any dental appointment that could cause bleeding (which is most appointments), you gain extra protection against bacteria that may be introduced into the blood stream.

These guidelines have changed several times, and I expect that the protocol for using antibiotics for this purpose will change again. I have encountered many patients that were never told (or forgot they were told) by their orthopedic surgeons about the need for this prophylaxis. That is why it is important that everyone who considers you as a patient looks out for your welfare and is familiar with the most recent guidelines for antibiotic prophylaxis.


Are Implants Worth The Cost?
Q: "All I want for Christmas are my two front teeth. I lost them in an accident, and I have a removable flipper that is loose and embarrassing. What are my options to have new front teeth, as I am only 22-years-old?"

A: I can see why you do not like your "flipper" or removable acrylic partial denture. These are usually intended to be temporary in nature, but some people use them for a surprisingly long time. We are in the age of implant dentistry, and that would be your best option (assuming that you have adequate bone support and a fairly normal bite). However, another non-removable option is a fixed bridge that is supported by crowns on the adjacent teeth. Although the cost of a bridge is somewhat less, there are drawbacks that make cleaning and maintenance more difficult. Additionally, unlike implant retained crowns that are self-supported, fixed bridges are tooth-supported; and since the bridge is dependant on the teeth it attaches to, if one tooth fails the whole restoration may fail. *Please see FAQ "Bridge Vs. Implant" for more information.*

Cost is usually the main aversion to having implants but when put into perspective, there is a great value in this type of dentistry. Replacing two teeth with implants, will probably cost more than a removable appliance or a bridge. However, given a realistic longevity of well-maintained implants, the cost would come out to be minimal over the next 20 years. Thus, value over time is an important perspective to consider when deciding on dental treatment options. There is also lasting value beyond the implants themselves- consider the value associated with self-confidence, happiness with appearance, good chewing function, and a smile's first impression...

If the up-front costs are difficult, several types of financing options can be considered. In fact, most dental offices that perform this type of treatment can help you with financing options. Most importantly, please don't price shop this type of precision dentistry. The reputation of the surgeon and restoring dentist should remain your top priority in selecting a treatment location. Our office would be happy to provide more information on your choices.


Baby Bottle Decay
Q: "Is it true that my baby can get cavities from the bottle?"

A: This is absolutely true. Cavities can form from any type of sugar or starch. This means that if the bottle has milk, juice, fruit drinks or soda pop, a child can get cavities if the teeth are exposed to these liquids long enough. Your mouth gets dry when you go to sleep, and if you replace your normal saliva (spit) with any kind of sugar containing liquid, you have set-up an environment for a cavity to occur. Thus, babies can get severe cavities (in less than 3 months) from going to bed with the bottle. Similar cavities can occur if the baby is allowed to carry a bottle or "sippy cup" around all day. The best rule to follow is that if you give your child a bottle or "sippy cup" any other time of day than mealtime, only put water in the bottle.


Baby Tooth Trauma
Q: "My two-year-old fell and bumped her front tooth. When it happened the gums bled a little and the tooth became loose. After a couple of days, everything seemed fine. Now, one month later, the tooth is turning gray. What should I do?"

A: Unfortunately, your daughter's tooth may not survive the trauma without treatment. Every tooth has a blood supply that enters through the root tip and forms a bundle within the tooth (this bundle is called the pulp). When a tooth is traumatized, the force of the root being pushed into the socket causes the "pinching off" of the blood vessel between the bone and the tip of the root. The blood that was already in the tooth begins to break down and releases iron and other bi-products. This is why the tooth begins to turn gray or brown. Eventually a bacterial infection occurs within the tooth, leading to a dental abscess. This usually involves pain and may negatively affect the development of the permanent tooth within the bone.

The tooth should be evaluated by a dentist, and most likely a root canal would be performed. If the permanent tooth was nearing eruption (around age 6) then an extraction would likely be recommended. Due to the child's age (2), treatment could be performed by a Pedodontist or your General Dentist. However, some General Dentists routinely refer this type of treatment to the Pedodontist. A consultation with your regular dentist would be a good starting point. Every child's tolerance to treatment is different, but with good communication skills, treatment can go quite well. A child will pick up on a parent's apprehension, so sometimes it is best if the parent is not directly in the treatment room, so the child is forced to communicate with the dentist and dental assistant.

Since a baby tooth root must be allowed to dissolve as the permanent tooth comes in, root canals on baby teeth are very different from those on permanent teeth. In conjunction with the root canal treatment, various techniques can be implemented to whiten or mask the darkened color of the tooth. Though this may not be the easiest of tasks on two-year-old, I have found that children are not traumatized by it, and the retention of the tooth is a great reward for the hard effort.


Bridge Vs. Implant
Q: "I have a missing tooth that I want to replace. I can't decide if I should have a bridge or an implant. What should I consider when making this decision?"

A: There are many factors to consider when making this decision, and you are smart to be giving it some careful thought. Assuming conditions are appropriate for both options, there are four remaining factors to consider. These are function, longevity, aesthetics, and cost. 

1. Function: An implant retained crown (IRC) does not depend on the adjacent teeth for support. A bridge is retained by crowning both of the adjacent teeth; the artificial tooth is suspended between the two crowns. As far as chewing, both are going to be very similar. Cleaning an IRC is easier because you can floss between the teeth. You must thread floss under a bridge, and this can be difficult depending on where the bridge is. If the adjacent teeth are un-restored, or in very good condition, then it is a shame to have to alter them in order to hold a bridge. An IRC would not alter the adjacent teeth.

2. Longevity: Clinical studies show both to be acceptable treatment options if appropriate guidelines are followed; however, the IRC is proving to be a more dependable long-term restoration. This is probably the case because titanium implants do not decay, and IRC's are not dependant on other teeth.

3. Aesthetics: Both bridges and IRC's can be very beautiful tooth replacements. The titanium implant will continue to stimulate the bone and therefore will prevent the bone loss that is associated with tooth loss. On a bridge, the gap between the gums and the fake tooth will usually increase with time and become less esthetic. The bone underneath actually shrinks due to lack of stimulation. An implant replaces the function of the tooth root and prevents this gradual bone shrinkage.

4. Cost: The cost of an IRC is usually higher for patients because most dental insurance companies do not cover the cost of the implant. They may however, cover part of the cost of the crown which attaches to the implant. The actual cost comparison is difficult to generalize and must be determined on a case-to-case basis. The number of teeth being replaced, the type of insurance, and the quality of the bone and surrounding teeth, are factors that will influence the treatment needed to obtain a good result.

Replacing a missing tooth will restore stability to the dental arches and prevent other teeth from shifting into the empty spaces. This shifting can cause a cascading set of problems which are best avoided if possible. No matter which option you choose, regular maintenance following the tooth replacement will protect your investment.


Broken or Failed Appointments
Q: "I was furious when I had to work overtime and my dentist charged me for missing my appointment. Is this typical?"

A: Many dentists and doctors are now charging for broken appointments without 48 hours notice. Some may look at the circumstances associated with the cancelled appointment and/or the frequency of cancellations for an individual person or family. It is important to realize that dental appointments are often scheduled for long periods of time, which are reserved exclusively for you. When an appointment is cancelled at the last minute, the dental office has no ability to fill that appointment. Other patients who may be waiting for an appointment can't often be contacted to fill an appointment at the last minute. The dentist must also pay their staff whether a patient is in the office or not, therefore idle time is very costly.


Buying Dental Insurance
Q: "I cannot afford dental treatment without insurance. Is there anywhere I can buy dental insurance?"

A: It is very difficult to obtain dental insurance that allows you to see a dentist of your choice, unless it is offered by your employer. You may want to speak to your employer about starting a medical savings account program at work which would allow your employer to set aside a portion of your income (before taxes) for medical and dental expenses. Depending on your tax bracket, this can save you a lot of money, since you will be using "before tax" dollars to pay for your treatment. The trick is to not set aside too much because if the funds are not used by the end of the year, they will be lost.

I would also recommend that you reconsider your inability to obtain dental treatment without dental insurance. You can receive preventative dental care for less than $350 a year. This is about 80 to 90 cents a day. Prevention is the key. By keeping up with your examinations and cleanings, you are essentially buying dental "assurance", thereby greatly reducing the likelihood of expensive problems down the road.


Career as a Dentist
Q: "I am interested in a career in dentistry. Can you give me some tips?"

A: Dentistry and its specialties will continue to fair well in the future. In fact, there will most likely be a shortage of dentists in the next ten years. That's the good news, I think. The bad news is that getting into dental school is very competitive. The grade point average when applying should be 3.5 or above. Also, community involvement, observation time in a dentist's office, and good scores on the Dental Admissions Tests (DAT), will weigh heavily on your application. Your admissions interview is also very important and should be taken seriously. The profession of dentistry, starting at the dental schools, is interested in the character and ethics of those entering the profession; therefore, anything that you can offer the admissions office that says something about your character and ethics would be very helpful.

Once you are accepted, the next hurdle is the cost. Most dentists graduate with student loan debts over $300,000, and setting up an office is around an additional $400,000 (even for the smallest of offices). All of these expenses come before you have even seen a patient! Since the loans for these expenses are often uncollateralized, interest rates will usually be higher. If you purchase an existing practice with proven cash flow, you are going to spend around $250,000 to $1 million, depending on the practice revenues over the last few years. Taking over a practice from a retiring dentist is very hard work. You are the "new" doc, and there is no guarantee that the patients will stay with you once you purchase the practice. You also become an employer, and you must be as committed to your employees' successes as you are to your own. In summary, although financial success in dentistry is common, you must be the type of person that can accept delayed gratification. You must also be a "people person," and you must make a great first impression. Your success in dentistry will build strongly on your ability to communicate effectively.

This may seem difficult, if not impossible, but there are four things that will make it easier while facilitating enjoyment in this profession. These things are honesty, morals, ethics, and compassion. Don't be misled into believing that dentistry is one of those professions that allow you to "get rich quick". It is hard work, and your success will be based not only on your skills, but also your character.

For the most part, dentists do not view other dentists as competition. Therefore, you will always find a mentor in the dental community. Never be too proud to accept the helping hand from an experienced practitioner. That being said, I hope to see you as a colleague in the future!


Child's First Visit
Q: "When should my child first start seeing a dentist?"

A: There are some differences of opinion on this question, but most will agree that age three is a good starting point to begin having professional cleanings. However, it is also important to have a one-year-old dental examination because this allows the dentist to assess the child for developmental abnormalities and early dental disease. It also allows the dentist to provide important information to the parents regarding how to best care for their child's teeth. Children can also observe an older, well-behaved child or parent receiving dental treatment, prior to having their own visit. Very little should be described to the child patient by their parents regarding what they should expect at their first visit. Leave that up to the dentist and the staff. They have a special vocabulary and expertise in making a child's first visit less threatening. Children who start off healthy with regular dental care typically stay healthier and are not as apprehensive about having their dental appointments.


Clenching and Bitesplints
Q: "I can hear my wife grinding her teeth at night, but when I wake her up, she has no idea that she had been grinding. Is this harmful?"

A: Night grinding can cause serious damage to the teeth, and it can cause significant muscle pain in the face, back of the neck, and temple regions of the head. When you are awake, protective mechanisms do not allow your muscles to contract beyond a certain point, no matter how hard you try. When you are asleep, those protective mechanisms are asleep, and your muscles are able to apply far more force to your teeth. This extreme force can cause cracking, mobility, and pain in the tooth. Extensive wear to the enamel can also occur, and the tooth may eventually lose its hard, protective shell. Restoring all of these problems, associated with night grinding and clenching, can be costly and complicated if not addressed early. The use of a CUSTOM made hard, acrylic bite splint while sleeping helps to protect the teeth, and often gives relief from muscle pain and spasms. A dentist would take impressions of your teeth and the appliance is fabricated in a laboratory in about one week. Dental insurance usually pays for part of a bite splint, but that depends on the dental insurance contract.

Some people have to wear their bite splint indefinitely. For others, a reduction in the level of stress in their life may cause the problem to resolve. Dietary intake of caffeine, a lack of Vitamin D, work-related stress, and other reasons have been proposed as a possible cause of night grinding. Early interceptive treatment of the problem is highly recommended.


Cold Sensitivity
Q: "My teeth are very sensitive to cold, and it is becoming very painful. What could be my problem?"

A: Sensitive teeth can be caused by several things. The root surfaces of the teeth are usually the most sensitive part of the tooth. If you have gums that are receded, exposing the root surfaces, then that may be a factor. Cracked teeth can also be very sensitive to cold, but they are usually sensitive to biting pressure as well. Most dentists will agree that carbonated beverages, due to their acidity, are commonly found to be responsible for long-term sensitivity and eventual tooth decay. If you are consuming more than two cans of carbonated beverages in a week, this is likely to be a factor in your sensitivity. Sensitivity is your tooth's way of communicating something is wrong, and you may not want to ignore it. I would recommend that you obtain a dental evaluation & dietary evaluation to help determine the cause of your problem.


Cold Sore Fever Blister Herpes Simplex
Q: "I frequently get fever blisters, and they are very embarrassing and annoying. Is there any cure for this problem?"

A: "Fever Blisters" and "Cold Sores" are terms used to describe what is actually a outbreak of the Herpes Simplex virus. This virus has both a genital and oral form and during the early outbreak stage, or "weeping" stage, the virus is contagious with direct contact. Kissing, glass sharing, etc. should be avoided during this stage of the outbreak. The virus can also be spread to the eye, and nail-beds through hand contact. The genital form can be spread orally and vice versa. There is no need to be embarrassed, because a very large segment of the population suffers from intermittent Herpes outbreaks. Unfortunately, there is no cure for the virus, but there are some prescription antiviral remedies that lessen the extent of the outbreaks. The virus can go dormant for long periods of time. Outbreaks most commonly occur on the lip, nose, palate, and gum tissue and can last up to two weeks. They start as fluid filled vesicles that rapidly rupture and begin to crust. Most people that experience the outbreaks can recognize the symptoms of an outbreak even before the outbreak can be seen. These early "tingly" sensations indicate the most ideal time to apply topical antiviral prescription ointments.

Outbreaks of the Herpes virus usually occur during times of stress, sun exposure, or from local irritations, wind exposure, illness (colds and flu), and menstrual periods. If outbreaks occur very frequently or extensively, a consult with your physician may be in order since weaknesses in your immune system can also make you more susceptible. As always, any lesions that do not resolve within two weeks should be evaluated by a dentist, oral surgeon, dermatologist, or physician.


Comfort During Dental Procedures
Q: "I am very apprehensive about receiving dental care because the dentist can never seem to numb my teeth completely. I have gone to different dentists and have always had the same problem. What can I do so that I can follow through with my needed dental care without the fear of pain?"

A: I understand your frustration, and there are indeed a small group of people that are very difficult to anesthetize. Unfortunately, based on your history of repeated failures to become numb, and the fact that several dentists have tried, you are probably a member of this group. There is good news! Several years ago, a different type of injection technique was improved called the intra-osseous technique or (trademark: Stabident). I have found this technique to be extremely effective on patients, like you, especially on the more difficult to numb, lower teeth. Many dentists have added this technique to their "bag of tricks" and you should be able to request it, when discussing your situation with your dentist. This technique places anesthetic directly in the area of the tooth. The small nerves going into the tooth are numbed, rather than trying to numb the major nerve trunk. It is not completely clear why some people are difficult to numb, but you are not alone. Hopefully the technique mentioned here will make your dental experiences much less stressful.


Communication Between The Patient and The Dentist
This is not so much a FAQ, but rather an important talking point that I would like to address. 

One of the most difficult things I face as a dentist is when a patient does not communicate what they are thinking about their treatment in my office. Hearing positive comments from patients always feels good, but it only confirms that what I am currently doing is being well received; however, when I hear a negative comment, it helps me to learn what I need to do better. To grow as a professional that serves the needs of others, both types of feedback are very important.

I think that a relationship between a doctor and patient is much like the relationship between spouses. You may not always agree, you may not always understand, but salvaging the time invested in the relationship is almost always worth opening a channel of communication. As my patients, if you do not feel comfortable while in my care, or while in the care of my office staff, please know that you can always come to me with your concerns. In fact, I encourage you to do so because of how highly I value honest dialogue. You will not offend, insult, or embarrass me. I enjoy watching my young patients grow older, and I enjoy the moments shared with my adult patients. My patients are like friends, and good friendships are worth the investment of time, effort, and open communication.