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A recent experience with a patient brought back a flood of memories from the dental school days. It was one of my early morning patient’s so the situation in hindsight all fit together. I am an early bird so I begin my day with my first patient at 7:00 AM. This patient was my third patient of the day and I was working on a lower tooth. As I began my procedure it became obvious that the patient wasn’t numb. I immediately stopped my work and gave the patient more anesthetic. Another attempt at beginning my procedure resulted in the same outcome – the patient was still not numb. I repeated this once more before turning to some alternative methods to make the patient numb. I was then able to complete my procedure successfully and comfortably for the patient. I’m sure there are some of you reading this that may have had such an experience happen to you. I then went forward and questioned my patient to see what I might discover and come up with some things that I thought I will share.

There is a host of ways that we as dentists are able to offer our patients to insure their comfort. The range goes from patients of mine that choose no local anesthetic to patients I have taken to Auburn Memorial Hospital operating room to care for them. As a member of the Dental Organization for Conscious Sedation I can also offer patients the option to treat them with virtually no memory of the visit! There is also a host of different ways to administer local anesthetic for the patient who has a hard time getting numb. All dentists are well trained in the anatomy of the head and neck so that any type of anesthetic can be given in a safe way. The techniques that are available to us dentists allow us to complete nerve blocks, place infiltrations and place anesthetic right in the bone to achieve profound numbness.

Now back to my patient from earlier in the day. I know that there are a number of factors that can make it difficult for a person to get numb with conventional anesthetics, the most common being Lidocaine. A discussion with this patient revealed that on his way to my office he stopped a Dunkin Donuts for a large coffee. This is where the dental school flashbacks come in. Now I won’t be too much of a geek and bore you with the physiology but suffice it to say that the caffeine in the bloodstream affected this patient in a couple of ways. One way is that the blood pressure is increased so that local anesthetic was cleared away quicker. The second is that the caffeine makes the tissues of the body more acidic and therefore neutralizes the anesthetic effect. If I had known this patient had the high test coffee prior to the appointment I could have then taken steps to avoid the difficulties in getting them numb.

If you are a patient who has noticed in the past that you have had difficulties in getting to that comfortable level where the procedure can be completed, be sure to speak to your dentist about this. We as dentists are trained to be able deal with these situations so that we can help our patients get to be as healthy as they can in a comfortable manner.

The American Dental Association commissioned a study back in the early part of this decade to look at tooth loss in this country. The results were quite impressive. In 1960 the average 65 year old American had 7 of their natural teeth left in their mouth. In the late 1990’s that number of natural teeth in a person’s mouth had jumped to 20. This study was very revealing that we as Americans are much more dental conscious and value our own teeth much more. As the population increased in number of teeth that they were keeping our dentistry became much more sophisticated. Missing teeth were replaced with the thought in mind that they would be there for a long time. The mindset that everyone was a future denture patient has left the profession.

There are a multitude of reasons for this sharp increase in the number of retained natural teeth including better periodontal care, better caries prevention and better materials for restoring these teeth. People were replacing teeth with fixed bridgework and implant supported teeth. This led at least one author to comment that the removable denture, either partial or complete, was a dying part of dentistry. I am making the statement that I disagree with the premise that removable dentures are dying in our profession. The techniques of removable prosthesis fabrication have evolved and changed right along with the rest of dentistry. It is important that we as dentists respect and recognize the fact that not everyone is interested in the amount of work that fixed prostheses or bridgework entails. The removable prosthesis is still a very valuable part of our treatment armamentarium for the prosthetic replacement of missing teeth.

Let’s start by examining the removable partial denture. In the past these were made with a metal framework to give the prosthesis rigidity. This framework is still a necessity but the improvements in the metals make it so the metal does not have to be as thick or as wide as in the past. An image comes to mind from my childhood of a family friend who had an upper partial denture. The image I recall is that of the metal clasp arms gleaming around the outside of the teeth as she smiled wide. There are several advancements in today’s dentistry that would have made it so the clasp arms were not the first thing my eye saw. We can use acrylic clasps that are flexible and either tooth colored or gum colored as one choice to make the clasps invisible. Another option would be to have an attachment built into a crown on the anchor tooth. This option eliminates the need for a clasp arm at all! The overall design of the partial can also be made as to eliminate the visible clasps.

How about the complete denture? You may be thinking how much can really be changed and updated with a set of complete teeth. Well there is plenty so hang on. The first thing that comes to mind is the teeth themselves. In the earlier part of this century the denture teeth were made of porcelain. Soon manufacturers were touting acrylic denture teeth as the next latest and greatest. The acrylic teeth work well but as anyone with an older denture with acrylic teeth can attest to they wear down considerably thus affecting the bite and the forces on the underlying bone. The notion that porcelain teeth caused more wear on the underlying bone became commonplace. As it turn out this notion was thought to be brought about by the manufacturers of acrylic teeth since they wanted to sell more teeth. A review of the dental literature reveals not one peer reviewed article giving proof to this notion that porcelain teeth wear down the bone faster. This needs further clarification which will be the topic of a future article. I’m getting on a roll here so the remaining improvements in complete dentures will be discussed as well. Thank you for reading!

Last month I got on a roll discussing the removable prosthesis as a viable and important option in the armamentarium to replace missing teeth. I would like to continue the discussion of removable partial and complete dentures. When I completed last month’s article I was discussing the differences between porcelain and acrylic denture teeth. It is well documented that the acrylic denture tooth will wear at a much higher rate when it is chewing against either a natural tooth or another acrylic denture tooth.

I would like to continue the discussion of what happens when a denture wears down and the biting surface of the teeth gets flattened off. Let’s start with a quick overview of how the teeth chew together on a denture. The bite is very different on a denture when compared to a full set of natural teeth. When we dentists design a bite for dentures the front six teeth do not contact the lower front six teeth. The back four teeth on each side top and bottom fit very intimately. This design is so the denture stays stable in the mouth. The way someone with dentures chews their food is very different from someone with natural teeth. The bite for a denture wearer is designed to hold the denture in place and not move around. There are many factors that can contribute to a loose denture but having a stable bite is the most important factor in keeping it stable.

So what does all of this boring bite discussion have to do with the type of teeth? As I mentioned before the acrylic teeth wear down quicker than porcelain teeth. If the back teeth are the only thing contacting and those teeth are acrylic and those acrylic teeth wear down then soon one of the rules of design for a denture bite will be violated. Due to the wear on the back teeth soon the front teeth will be touching. Once the front teeth touch a situation called Kelly’s Triad occurs. As the name implies Kelly’s Triad is a three part phenomenon that occurs with all three parts occurring together. The first is the destruction of bone in the upper front jaw due to the biting forces of the denture. As the bone is destroyed in the upper front the denture will sink upward. The lower will then over close up to meet the upper and the third part is the downward growth of the back upper bone. This leaves a very difficult situation for the dentist to restore.

Please don’t think that I am saying that all acrylic denture teeth are bad. That is not my point. The point is that once the denture has been made most people think they are done with seeing a dentist. In truth it is best for a denture wearer to have the denture bite evaluated at least once a year. If there are signs that the bite is off or there is wear, these problems can be attended to right away. Also, it is important that every patient have an oral cancer screening at least once a year.

For all of my team I would like to take the opportunity to thank all of you who participated in this years Smiles For Life children’s charity fundraiser. I am pleased to share that our office raised $8800 for children’s charities. Half of the money stays right here in Auburn and will benefit the Auburn YMCA scholarship fund. This fund is to assist underprivileged children be able to utilize the vast array of services at the YMCA. The remainder of the donations goes to the Garth Brooks Teammates for Kids foundation.

A couple of recent events have prompted me to write on a subject that affects a segment of the population that is the most susceptible to dental disease. The topic is specifically nursing bottle caries but I would like to include anyone in the age group of the 0-5 range as a possible victim. As you are reading this you may be thinking to yourself that you don’t have any children so why should I continue to read this column. In fact, just about all of us from the teen population that may have a younger sibling to a grandparent who has young grandchildren can be a positive influence on the dental health of a young child.

The term “Nursing Bottle Caries” comes from a specific pattern of dental caries or cavities that is seen on a child who is put to sleep with a bottle. It isn’t so much the bottle itself as what is in the bottle that causes this sad situation. When there is a sugary liquid in the bottle and the child is sleeping with the bottle the sugary liquid is sitting on the child’s teeth constantly over a period of time and causing the decay. The main pattern of decay that is seen is the six upper front teeth on the side facing out are the teeth to rot. It is extremely important that if a child is allowed to sleep with a bottle that only water is put in the bottle. Fruit juices, artificial fruit juices, and milk all contain plenty of sugar for the bacteria in the mouth to feast on and cause the child to have to deal with the consequences of badly decayed front teeth. One of the events that I alluded to in my opening sentence was a young girl who was getting picked on badly by classmates because of her black smile. The pain in her teeth was causing her to not be able to enjoy foods and her speech was affected as well. Please ask yourself the question: “Do I want my (child, grandchild, brother, sister, niece, nephew…etc) to have to endure that type of pain and embarrassment?” Sometimes I am asked why not just take those teeth out since they are “just baby teeth”? By removing those teeth there are several grave consequences. The speech development is affected, the capability to eat is affected, and the self esteem of the child can be crushed by not being able to smile. Face it, as I have witnessed, kids can be brutal to one another. Is that what you want for your child?

The second event that prompted a discussion on this topic was the veto by Governor Patterson of a bill that would require a warning label on “sippy cups” to state that these cups put the child at greater risk for dental cavities. Now this can be argued both ways about whether or not it is the government’s responsibility to go that far in requiring such a label but that isn’t the point of this discussion. The point is that there have been studies that show that the incidence of cavities in children is much higher when they use a sippy cup. As I talked about above, it comes down to what is in the sippy cup that the child is constantly bathing the teeth in.

To help prevent the incidence of dental caries in the most susceptible population please heed several suggestions. The first is to never put a child to sleep with a bottle unless it contains only water. The second is if a child uses a sippy cup for drinking please be sure to either brush their teeth or at least rinse with water after a sugary drink. I would be one happy dentist if I never had to see another 3 year old come in to my office with a mouth full of cavities.

A comment from a patient the other day inspired this month’s topic. I had gone down to the room of one of the hygienists on my team to examine a patient at their 6 month preventive therapy visit. I sat down and began examining the skin of the face and neck when the patient asked me what exactly I was looking for. It made me think. Maybe our patients don’t know what we are looking for as we dentists examine them. The exam is much more than coming in, picking up a mirror and explorer and checking just the teeth. Each dentist has their own method and technique of performing the exam. Rest assured this important step is not missed.

So what is it I am looking for? This particular patient that prompted me to discuss oral cancer asked me the question as I was looking along their hairline and lifting back their bangs so I could examine the scalp and forehead. If you were to look at the Skin Cancer Foundation website (www.skincancer.org) you would find that Basal Cell Carcinoma is found mainly on the face, scalp, ears, neck, shoulders, and back. Let’s see, 4 out of 6 of those are right front and center to me when I go to look at a patient at their recall exam. Sure makes sense for me to check! So for this patient I told them I was looking for any signs of skin cancer and if there was anything that I thought was suspicious I would make a referral to my dermatologist colleagues for further study.

My exam next took me inside the mouth. I was looking for various types of cancer in each area of the mouth. I took a gauze square and grasped the tongue as my patient put their tongue out for me. In the mouth the most common site for a squamous cell carcinoma is along the side and underside of the tongue. The rest of my exam was completed, looking under the tongue, the floor of the mouth, the throat, the roof of the mouth as far back as I could see and the lips both inside and out.

Lets’ talk about oral cancer a bit. 2010 is the fifth year in a row that there has been an increase in the rate of occurrence of oral cancer. That is one scary statistic, especially to us dentists who are the ones who are looking in the oral cavity every day! The other scary statistic is that if oral cancer is detected in the early stages the survival rate is 80-90%. Unfortunately the majority of oral cancers are found in the late stage where the death rate is 45% and the treatment is very disfiguring. When we dentists complete the oral cancer screening there are tools at our disposal to make a decision as to whether a lesion needs to be examined further. Items such as a brush biopsy allow us to make faster decisions to refer for biopsy. Any lesion that is present for 2 weeks without resolution should be considered suspect and worthy of biopsy or referral. We now have further screening devices including lights and rinses which have proven to be screening tools but studies have shown they are no more effective than a thorough visual exam.

Oral cancer is such a disfiguring cancer that it behooves every dentist and hygienist to be part of the process to detect it early. As a patient, you can help to prevent oral cancer by eliminating tobacco use, both smoking and spit tobacco, and limiting alcohol use. Be sure to visit your dentist regularly and tell them if there are any sharp areas on teeth, fillings or dentures as long term exposure to these can precipitate cells to become irregular. Hopefully we can improve the detection of this cancer.

As a doctor of the oral cavity my job is to diagnose and treat dental disease as well as other pathologies of the mouth. Often times I am asked the question, “Why do I get cavities?” or “How can I help to prevent decay for myself and my children?” This brings to mind an important point to understand – dental caries, or cavities, is one disease that the body cannot heal by itself. If you have a cold, you can control the symptoms until your body’s immune system catches up with and kills off the virus. If you have strep throat your physician will prescribe an appropriate antibiotic so that the bacteria can be killed and the body will heal. If you have a cavity the only way that the tooth can be fixed is for the decay to be removed and the tooth restored.

When I have a patient that comes into my office with extensive decay I not only have to restore their teeth to health but also find out what is the cause of the decay so the patient can prevent further disease. One of the most common items I hear when examining the patient’s diet is soda. The worst case I ever heard was one patient who consumed two 2 Liter bottles of soda per day! Let’s look at how decay starts with the help of soda. First, the sugar in the soda combines with bacteria that live in your mouth to form acid. This acid plus the acid in the soft drinks attack the teeth. Each acid attack lasts about 20 minutes and the acid attacks start over again with each sip. The ongoing acid attacks weaken the enamel. Cavities begin when the enamel is damaged. Remember that diet or sugar free soda still has acid that can harm your teeth and although sports drinks or fruit juices aren’t carbonated they still contain sugar and acid which cause decay. One simple home experiment is to take one of your child’s baby teeth that has fallen out and put it in a glass of soda. Check it every ½ day and see how fast the tooth dissolves.

In 2000 The University of Minnesota School of Dentistry conducted laboratory tests to analyze what the pH (or how much acid) is in drinks. A neutral pH is 7.00 which is water. Battery acid has a pH of 1.00. A few examples of common drinks are Mountain Dew – pH = 3.22, Diet Coke – pH = 3.39, Pepsi – pH = 2.49, Gatorade – pH = 2.95. How about sugar content? The USDA statistics for a 12 oz. can of Minute Maid Grape Soda is 11.9 tsp of sugar! Same with Orange Slice. Hawaiian Fruit Punch is 10.2 tsp. You see my point.

So what can you do to help prevent decay? The first would be to drink soda in moderation. Don’t sip on soda for prolonged periods of time. This continuously starts the acid attack over. Use a straw so the sugar stays away from your teeth and rinse your mouth with water to dilute the acid and sugar. Be sure the last thing you put in your mouth before going to bed is a toothbrush. Your saliva flow decreases when you sleep. If you leave the acid and sugar on your teeth all night you are providing a perfect environment for the acid and sugars to do their dirty work on your teeth. Read the labels of what you are drinking. You may be surprised what you find. Drink water instead of soda or fruit drinks. It has no acid, no sugar and no calories and it contributes to overall health. Be sure to have regular dental exams and cleanings. Flossing regularly and using a fluoride toothpaste will help remove plaque (the sticky bacterial film on the teeth) and help prevent tooth decay.

As much as I enjoy what I do in restoring people’s smiles and caring for their dental needs, I have to share with you that it is extremely rewarding to have a patient come in to my office with perfect teeth, perfect home care and no more dental needs than periodic preventive visits.

After a long harsh central New York winter many of us are heading out into the bright sunshine in full force to either work on our gardens or groom the lawn. Perhaps a more leisurely activity is in order such as a softball game or 18 holes of ripping out hair over a little white ball or my favorite – tossing a line out after the ever elusive smallmouth bass. No matter what you do, the sun’s rays are beating down on us. So why is it that a dentist would care?

The thought came to mind as I was running through my oral cancer screening that I do on each and every patient at their recall visit. I start on the side of the neck and evaluate the skin for any lesions that may look suspicious check the skin up along the ear and behind the ear and along the hair line. Along the hair line is a common place for a Basal Cell Carcinoma. Not every patient gets evaluated by one of the fine dermatologists that we are blessed to have in this city so if I might be able to pick something up early and make an appropriate referral I may be able to help out that patient with a lot more than teeth.

What really hit home with me was when I was running through the skin check on a child. I had traditionally done the skin check on a child but never in a million years did I think I would find anything. Well lo and behold wasn’t there an article about a study that was done showing that the really bad skin cancer, Malignant Melanoma, has been found more and more in children. All of the sudden my skin exams on children have taken on a greater purpose since I doubt that Dr. Foresman and Dr. LaDuca don’t get to see many children for yearly exams. So now when you see your dentist looking closely at the skin of the neck and hairline of your child, there is a reason for that which is based in science. Also, when they are looking at the tongue closely – the side and the underside – once again, there is a specific thing that we are looking for.

I can’t stress enough the prevention aspect of malignant melanoma. That goes for any skin cancer for that matter. Skin cancers that are found in the mouth generally have a very poor survival rate. The other issue with oral cancer is that it is a very disfiguring cancer. Once it is detected by the dentist it usually has progressed to a point where radical surgery is needed. Malignant Melanoma has been found in the mouth. It is rare but it has been found. An ounce of prevention is well worth it and a pound of prevention is better. Sunblock on any exposed skin is a must. Be sure to protect the lips. Skin cancer can easily manifest on the lips as well. Summer is coming and the kids will be out of school. Please cover those kids appropriately so they don’t burn. If you see any suspicious spot on the skin of your child or grandchild, please be sure to have it checked by their doctor.

Dr. Michael Keating is in private practice in Auburn at the Health Central Building. He can be emailed at DrMike@KeatingFamilyDentalCNY.com

As we grind through the winter months, February comes upon us. For us in the dental profession February is symbolic for kids. This month every year is Children’s’ Dental Health Month where the dental profession makes a concerted effort to spread the work through education of the importance of oral health. This endeavor is especially worthwhile since our children in Cayuga County have one of the highest rates of dental caries (cavities) in New York State.

Education is vitally important but it is more than just relying upon teachers in the school systems to complete the task. Although the lessons of proper oral health are taught in the schools, the teachers are already overwhelmed with required curriculum items. The lessons that are taught have to be carried on by the parents or guardians at home. A prime example of this would be a lesson on proper health drink choices. If a child learns what are healthy chores and what are bad choices and the only drink choices available to them at home are unhealthy then the message is undermined.

There are a number of preventive measures that are available to our children. All of these measures are aimed at helping keep decay off the teeth. When we talk to children about their teeth and preventing cavities we will often refer to bugs on the teeth. Now sometimes with children the truth may be stretched to get a message across but in this case the bugs are the truth. Let’s take a quick look at how a cavity forms. We start with a hard solid surface, enamel. In fact this enamel is the hardest substance in the body! When we eat foods that may stick to the teeth, for instance a Snickers Bar, the bacteria that normally live in our mouths land on the teeth and colonize there. These bacteria live on sugar. The more sugary foods we eat the more the bacterial invasion. Now these bacteria are enjoying the sugar in that Snickers Bar and as they ingest the sugar acid is produced. This acid lies on the hard enamel and breaks it down. Once there is enough breakdown a hole forms in the outer shell. Think of the tooth as an M&M with an extra liquid layer in the very middle. Once the acid gets through the shell and hits the softer inner the tooth breaks down seven times faster! If the bacteria get too far they get to the liquid center where the nerve is. It makes me cry to see children with cavities that are so deep they are into the nerve.

Now that you have an understanding of how a cavity forms, it is easy to see what are healthy food choices and what are not so healthy. I will be the first to admit to sticking my hands in the candy basket but it’s not an everyday occurrence and thorough brushing and flossing and rinsing will help. Think about soda and how it is a double whammy. You have the bacteria forming acid on the tooth and then the soda, regular or diet, that is extremely acidic and enamel is under a huge assault!

So why not start a trend in your family? Begin some new habits by making healthy choices for your children during Children’s Dental Health Month. Once you start with healthier choices, continue on. Don’t stop at the end of February. Reinforce what your children are being taught in school so they can have a better chance of excellent dental health.

It was a typical December evening just a few months ago which brought back some unpleasant memories. It was a blustery, snowy night and I was in prime “male-gender” position: in my recliner, remote in hand, my dog snuggled up between my legs and college basketball on the television. I was watching Syracuse play someone, which team is not important. During one play there was a clash of the titans underneath the basket going for a rebound. One player came out of the pack with the ball and another player came out with a handful of blood and a large chunk of his front tooth in his hand.
Shortly after this my cell phone rang and it was one of our awesome Auburn Memorial Hospital Emergency Room physicians. A JV basketball player in a high school game had trauma to his face and sure enough, his front tooth was knocked out. Thanks to my hospital experiences, treating this patient is no problem for me. Fortunately, the tooth was replanted immediately and the ER doctor finished the repositioning.

I rolled back in my head about 20+ years to my undergraduate days at Siena College. It was an intramural game. At 6’ 5” tall I was the guy that was always sent down low to rebound. I came down with a ball, turned to pass it and smacked right into an elbow from another player. There was nothing malicious about it, just one of those collisions that happened. After a lot of dental work, all is back together (minus three of my own teeth).

After finishing my scary flashback, I thought about the experiences that I have had either during my residency at Strong Memorial Hospital or in my own practice with dental trauma. It’s amazing how much trauma could be prevented just by having a mouthguard in place. When you think of a mouthguard, you think of its function being to protect the teeth. This is true. In fact, studies have shown that a mouthguard will lessen the risk of injury to the front teeth by 90%. The guard will also lessen the risk of damage to the back teeth when the lower jaw is struck and the teeth are bashed together. Let’s consider the rest of the purposes of a mouthguard. It prevents lacerations to the tongue, cheek and lips by preventing a tooth from piercing the tissue. The guard will lower the risk of jaw fractures by absorbing the energy of a traumatic blow to the chin. When the lower jaw is hit from the front or the side there is a huge risk of concussion. The lower jaw is jammed backwards into the skull in this type of trauma and can also cause damage to the joint itself. A mouthguard will absorb and redirect the force of a blow to the lower jaw thus lessening this risk.

The American Society of Testing and Materials has three classifications of mouthguards:

Type 1 is a stock guard. In other words, one size fits all. This is the least fitting, the most bulky and can interfere with speech and breathing.

Type 2 is the mouth formed. There are two styles of this type. The first is a rigid outer with a soft lining that needs to be replaced at each use. The second is the common “boil and bite” style. What many people are not aware of is that these can do more harm than good if not fitted with precision.

Type 3 is a custom fabricated guard. This is made over a cast of the teeth. Impressions are made of the upper and lower teeth then a thermoplastic material is vacuum formed over the cast of the upper teeth for precise fit and comfort. The bite is then adjusted to the lower teeth for an integral fit.

The Type 3 guard is going to give the maximum protection against jaw fracture, concussion and also tooth damage. A traumatic blow to the lower jaw at any angle can have the forces evenly distributed along the mouthguard material and transferred evenly to the upper teeth. If a mouthguard is uneven in the slightest bit the chances of concussion or jaw fracture are greatly elevated. If the lower jaw receives a blow straight on and the bite is uneven then the jaw will be caused to tilt by the mouthguard. The force of the blow will then be accelerated to the uneven side thus causing a transfer of force even greater to the joint. This will more likely result in fracture, concussion, or damage to the joint structures.

When it comes to mouthguards in sports, the choice becomes obvious. Not only the choice of wearing or not but what type. In my years as a dentist I have heard many excuses for why athletes don’t wear mouthguards unless they are mandated. When those excuses are put up against the reasons in favor of wearing a guard such as medical bills, dental bills, time out of school or work, permanent damage to the jaw joint structures or surrounding structures, the excuses pale in favor of the reasons. There is one college basketball player with stitches in his lip and a busted tooth and one dentist in Auburn with three replaced teeth because of not making the right choice. If you play sports, see your dentist and have a proper mouthguard made.