Why People Hate Teeth Cleaning at the Dentist

Dental Revelations Blog-3916

We do the teeth cleaning with these “hooks”. We like to call them curettes.

The most common things patients say to me when they enter my practice for teeth cleaning are

I hate this

It hurt a lot last time

Are you going to use the hooks??

But once we are done with the treatment they are visibly relieved, thank me for being gentle and share their story about the previous dentist/hygienist who did the scaling. The stories are horrendous and it often makes me feel ashamed of my colleagues. Why are they failing in very simple task – managing the pain?

For those who now think that I must not do the scaling very well if it doesn’t hurt:

Me being gentle does not equal me being less thorough with the scaling. I go to those 12 mm deep pockets with my hand scalers and sometimes even without any local anaesthesia. I remove all the subgingival calculus that is possible without surgery – if not on the first visit then on the following visits. And yet the patient thank me for being gentle.

How is this possible? Let me tell you how. If you are a patient, there is information for you at the end of this post.

Butchers

When I was at dental school I worked as a nurse in private practices (I have written about this period in my life in my previous post). I was a nurse for a young dentist who was performing a scaling for the patient. It was the most unpleasant piece of treatment I have ever witnessed. It was a bloodshed. A complete massacre of the gums.

The patient did not have severe gum disease – just gingivitis. The dentist did not use local anaesthesia and took her sickle and started the scaling (or her interpretation of it). Pieces of interdental papilla were flying around and the mouth was filling up with the blood… I am slightly exaggerating of course, but just slightly.

The patient was wriggling but did the dentist offer local anesthesia? No she didn’t. She carried on with the massacre. All I could do was to place my hand gently on patient’s shoulder as way of comfort in this horrible experience that should never had happened.

In the end of the treatment she had removed all the interdental papillae from patients mouth. Instead of the interdental papillae there were now dark red blood clots. Hands up everyone who knows this should not be done! I hope there are some of you.

Now this was my experience that I witnessed. The rest my patients have told me. The stories do not vary a lot from what you just read.

The Pain Threshold

All the patients are different when it comes to the pain threshold. Some people cannot take any pain and require topical anaesthesia even for probing. Some go through the whole scaling without any complaints and do not want to have a local anaesthesia even when suggested.

But the most important thing with every patient is to tell them about the options for pain relief.

When I see a patient for the first time they are often very sceptical and think they need all the possible pain relief there is. In these cases I suggest that we first try without and if the pain relief is needed it can be applied any time.

The reason I do this is that I have noticed that the fear of the pain is sometimes greater than the actual pain. Once the patients realise this they relax.

Doing It in One Go

This is not how you should do it.

When the gums are inflamed they hurt. As a patient you do not want anyone you just met digging your tender gums with a sharp instrument.

So on the first visit it is important to teach the patient better oral hygiene routines and techniques and get rid of the supragingival calculus (visible calculus) and some of the subgingival (invisible) as well (as much as the patient can take the discomfort).

I rarely use hand instruments on the first visit. I concentrate on very thorough scaling with the sonic scaler (EMS is my favourite). I might still use Mini and Micro Sickle for the lower front area as there is often calculus and stains left after the sonic scaler. Plus the patients loooove to get shiny white smile on the first visit.

Remember to tell the patient that there is (invisible) calculus still to be removed as they might not return for the following visits when the bleeding of the gums stops. It is important to mention that if the calculus is not removed it can result in periodontal abscess and bone loss. Eventually the gums will start bleeding again.

After this I let the gums heal at least for a week. It is much easier for the patient and for me to perform the subgingival scaling when the gums have healed and shrunk. Sometimes they have shrunk that much that not much of the calculus is hidden below the gum line – but this requires the patient to do his share with the oral hygiene at home.

Technique of Scaling

This is where most of the “butchers” fail. They either use wrong tools or right tools but wrong technique.

When I began working in my first surgery abroad and saw the scalers I was supposed to use I declined kindly and persuaded the owner to order me the instruments I preferred. It was a difficult task as the hygienists had used those “instruments for giants” without complaints. I explained that the curettes were far too big for anyone’s teeth. They were clumsy and big and the metal was very “stiff”. Luckily the owner was a wise dentist and I was allowed to order new ones.

The scalers I have by default for all the patients are:

Micro-Sickle by LM

Mini-Sickle by LM

Mini-Syntette by LM

With these I can do simple scale and polish but if there are pockets deeper than 3mm I have curettes at hand in a sterile pouch and I choose them by the location and the shape of the pocket. I have sets of curettes in pouches as listed below:

Mini-Gracey 11/12 by LM

Mini-Gracey 13/14 by LM

Gracey 11/12 by LM

Gracey 13/14 by LM

and

Mini-Gracey 17/18 by LM

and

Gracey 17/18 by LM

and

Furkator KS by LM

Please note that I do not get any financial benefit of writing about certain brand of instruments.

Chlorhexidine After Scaling

I always rinse the deep pockets with syringe filled with 0,12% chlorhexidine liquid or gel. It reduces the risk of complications.

Sharpening

Blunt instrument results in slipping of the instrument either to the patients gum or your finger. Neither is good. Blunt instrument also does not remove the calculus – it only polishes it.

It is very important to sharpen the curettes after each use (sickles and syntette do not require sharpening that often). It doesn’t matter if you do it by hand or by sharpening machine. Both of them require skill but the only difference between these two is that the hand sharpening extends the life expectancy of the curette.

I sharpen my instruments in a cycle of hand sharpening two to three times in a row and then machine sharpening once. I sharpen once a week all the instruments that have built up in a week. For you being able to do this you need at least a week’s worth of instruments in the surgery.

Tip: When you sharpen your instruments always check with a test stick first if the instrument is in fact sharp enough. Sometimes if you have used the instrument only for couple of strokes it remains sharp.

Informing the Patient About the Post-Scaling Complications

There will be tender gums after any scaling and polishing. But the patients can take it much better when they are informed about the different kinds of complications that might occur and how they can manage them.

The most common complications and ways of relieving them are:

  • tender gums – cold drinks/food, paracetamol/ibuprofen, never aspirin as it might make the gums continue bleeding
  • taste of blood in the mouth – normally it is resolved by the next day
  • sensitivity to cold – sensitive toothpaste, leaving the toothpaste in mouth after brushing, avoiding acidic food/beverages

It is also good idea to mention the less common complications and the ways of relieving them:

  • extreme pain in the gum caused by secondary infection that lasts for many days – salt water rinse, chlorhexidine rinse (alcohol free) or to see your dentist if the symptoms persist
  • pain around the partly erupted wisdom teeth – chlorhexidine rinse or to see your dentist if the symptoms get worse despite the rinsing
  • periodontal abscess – to see the dentist

If the patient is left untold about these complications and if they do happen it is very likely that the patient blames you. And he will tell this to ten of his mates (marketing rule) even though there was nothing wrong with your scaling skills.

But when explained that you have now disturbed the bacteria balance in the deep pockets by scaling and even though it was necessary and important thing to do the bacteria in the pockets sometimes – in rare cases – do not like it and the situation might get worse, you will have much more satisfied patient even if complications occur. A patient that still trusts you.

Conclusion

Having the teeth cleaned at the dentist should not be painful. Some discomfort is acceptable but it should always match to the patient’s individual pain threshold. And after the scaling the patient’s gums should not look as if Jack the Ripper had done the treatment.

The right technique of the scaling is difficult to master. But once you do, it will be more rewarding for you as you see better healing results with the gums and a happier patient. Here’s one video about hand scaling technique (it’s not ideal video but hopefully you get the idea) but I’m sure hands on courses are available at the dental schools as well.

For the hygienist – please do not accept just any hand scalers. Check out different brands of curettes at the dental show case and order couple of them to try out. If you are unsure with your technique start with the mini-curettes.

For the patient – If you’ve had bad experience at the dentist with the cleaning of the teeth seek another one. Change until you get proper cleaning, relevant info and oral hygiene instructions. Be prepared to have at least two visits.

When you maintain good oral hygiene habits and see your hygienist for regular teeth cleanings (interval decided individually, see my previous post) you will never ever need to go through the same experience again. It takes just one visit to clean your teeth and it is much less painful.

If you do not do your part at home and leave longer period of time than recommended between the cleanings it often takes two visits to do it. And once again it is unpleasant for you.

I worry over the fact that the patient is unable to tell if the scaling was done thoroughly. I have written about this before. It is not until the patient by chance sees somebody who recognises the gum disease and masters the comprehensive treatment for it, when they realise the poor quality of the treatment they were getting in the previous practice.

That, my dear readers simply is not acceptable in the modern dentistry. So revise, revise and revise. Trust the patient’s reaction. If they complain often that it was a horrible experience then something is wrong with your scaling technique, your tools or your chair side manner. Swallow your pride and do something about it.

 

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About Prince by Tressiemc

I have no talent to write about the musical achievements of late genius Prince. I am just somebody who has listened and danced to the beat of his songs since the teenage years.

Somehow it feels like the the world has changed when Prince passed away. I’m sure you don’t mind me stepping out of the dental theme for a little while. Let this quote by Tressiemc be the voice of how I feel.

I spent a lot of years wanting to feel the holy spirit. I tried all the religions in North Carolina and never happened upon it until a Prince concert in Greensboro, NC. Genius was as close as I ever came to god. _______ There is the kind of genius that works hard. You see Michael […]

via There Are Thieves In The Temple Tonight — tressiemc

Money-Saving Advice on Dental Visits

Dental Revelations Blog-3892

Are you seeing your dentist for a check-up too often?

Here we go again. I am annoyed about something that is waiting to burst out. I have written about integrity of the dentists in one of my previous posts and today I am going to touch the same subject.

This post is about dentist check-up frequency patients should have.

Many dental practices very commonly advise people on their websites and in the surgeries to see dentist every three to six months and they justify this by prevention of bigger dental problems.

A revelation:

Recommending the same check-up interval to all the patients is not up to the standards of modern dentistry. It is merely (once again) about maximizing the profit of the practice.

Check-up intervals should be decided after carefully evaluating the current status of the oral health, general health and oral hygiene routines. I will list the guidelines that are practiced in one of the leading countries.

Managing Decay

24 to 36 Months Interval in Check-Ups

This concerns the patients who have

  • no treatment requiring decay
  • no early decay that needs to be stopped or reversed
  • not had any decay for many years

It is important to check the patient’s eating habits to make sure that they are not harmful to the teeth and encourage patient to change them if needed.

6 to 12 Months Interval in Check-Ups

This concerns the patients who have

  • one or more early decay or advanced decay

It is important to make a plan together with a patient to stop the decaying. This might include visits to the hygienist.

Exceptions

Certain groups of people might need to see dentist more often than advised above. These are:

  • children and youngsters
  • people with illnesses and medications that reduce saliva flow
  • users of intoxicants
  • immigrants of certain countries
  • people with dental phobia
  • people with big life events (pregnancy, divorce, military service, retirement)
  • people of low education
  • smokers
  • people with illnesses or injuries that cause disability that prevent good oral hygiene
  • people with harmful eating habits and/or poor oral hygiene
  • people who use fluoride toothpaste less than twice a day
  • mouth breathers
  • people who are undergoing orthodontic treatment
  • people with dentures
  • people with erosion on teeth
  • patients who have had teeth extracted/root canal treated due to decay in the past 3 years

Managing Gum Disease

3 to 12 Months Intervals in Maintenance Visits

After a comprehensive therapy for the gum disease the patient needs to see periodontist/hygienist regularly for the maintenance visits. The interval of the maintenance visits is based on many risk factors like

  • severity of the bone loss
  • smoking status
  • overall health (diabetes)
  • genetics
  • age related (medications, illnesses)
  • gender (male)
  • low socioeconomic status
  • poor oral hygiene
  • condition of the teeth (restorations – especially subgingival crown margins, removable dentures)
  • furcations
  • anatomic abnormalities
  • residual pockets

The more advanced gums disease the shorter the maintenance interval. The more risk factors the shorter maintenance interval.

Conclusion

To recommend all the patients the same 3-monthly check ups is simply madness and it stinks of foul play.

Dear patients,

please be advised that you most definitely do not need to see a dentist every three months unless you fall into one of those risk factor categories above. But even in these cases a top-notch oral hygiene habits can make wonders and extend the check-up interval from three months to six.

Also if you do want to see a dentist every three months there is no harm done. Apart from you needing to pay unnecessarily for a treatment you don’t need.

Yours sincerely,

Dental Revelations Blog

Times change. So does the dentistry. Sticking to the old ways – “it has always been done like this” – is simply not what modern dental practice should do.

More on the subject click the links below.

NHS

Daily Mail

NICE – National Institute for Health and Care Excellence

Do You Recommend Toothpick?

Dental Revelations Blog-24529

Toothpick or no toothpick, that is the question!

I will once again return to the times when I was a student in dental school and knew only little of the dentistry.

We were learning about cariology and were advised to bring in dental radiographs (x-rays) if we had any. I had had a panoramic radiograph taken recently and the teacher – a specialist in cariology – took a look at it. He said to me:

“You should use a toothpick”

I was very surprised and said to him that there is no way I can fit the toothpick in between the teeth. He showed me from my x-ray that there is enough space between the teeth for the toothpick. But I was not convinced (thought that he was wrong) and carried on using a floss for many years to come.

The reason why this occasion came to my mind was that I was reading through health and dental blogs to get ideas for my next topic and I ran into several blogs that wrongly advice people against using a toothpick. I got this certain annoyed feeling inside of me and I knew I had to write about it.

Toothpick Widens the Gaps Between the Teeth and So It Is Supposed To

I have worked with many periodontists and learned that floss is not – by far – the right tool when we try to tackle the gum disease. It does no massaging for the gums which is needed when we try to make the gums firmer around the teeth (plus it won’t remove all the bacteria). When the gum gets firmer it shrinks and leaves less space for the bacteria to hide and cause the disease.

When I moved abroad I very quickly understood that a toothpick was not considered to be a good tool for cleaning between the teeth. I received wondering commentary from my colleagues when they realised I am recommending it. It was considered to be old-fashioned, ineffective and even harmful to the gum. I had to explain the reasons for recommending it again and again:

“The toothpick – the triangle-shaped wooden one –  works well initially when the patient has inflamed and swollen gums. It is cost-effective, easy to use and effective in massaging the loose gum. Once the gums have healed and firmed up we can determine better which sizes of interdental brushes are the best ones to use.”

The patients often fear that whatever they are using to clean between the teeth will widen the gaps. I tell them that it might actually happen but in that case it is only a good sign. I explain to them – with their x-rays – that the bone levels will determine how much the gaps between the teeth will widen.

If the bone around the tooth has receded as a result of the bacteria presence and inflammation and there is swollen and loose gum on top of it, it is an unhealthy situation and will result in more bone loss eventually. The gum needs to be firm on top of the bone so that it can better resist the bacteria.

And the only way to get firm gum is by massaging it. This can be done with the triangle-shaped wooden toothpick by pushing it gently but firmly between the teeth as far as it goes and repeat it couple of times. If there is bleeding at first it is also a good sign – the toothpick is doing its job. The bleeding will stop if the toothpick is used for a week in every between the teeth every night.

Suspicion

People often leave the practice unconvinced of the advice they were given. But the ones that do as they were told despite being sceptical are gobsmacked by the way the bleeding (and hurting) stopped.

I recall having a phone conversation with a patient who had an advanced gum disease and who had recently seen me for the first visit of the course of treatments. I had advised him to use purple interdental brush (1,1mm) but he wasn’t convinced about it and this was the reason for to phone call. He thought the brush was too big as it hurt. I told him that the only thing he can do is to try to prove me wrong. To follow my advice and see if I’m wrong.

He carried on using the interdental brush and about week later I received another phone call from the patient. He wanted to share his amazement and joy about his gums that had stopped bleeding. He was thankful for the correct advise and said that he had suffered from bleeding gums for all his life and only now – at his fifties – he managed to stop the gums bleeding.

The pain makes people think that something they use is not right for them. That’s why it is important to advise patients that when they have a gum disease (any stage from gingivitis to severe periodontitis) it will be painful at first when they begin using the interdental brush or toothpick – there’s no way around it. I always tell patients that for about week they need to suffer from tender and sometimes very painful gums. But if they persevere with the use of interdental brush/toothpick as advised they will notice it won’t hurt after a while.

 Conclusion

I have said this before and I am saying it again – do not believe everything you read from the internet. I have run into several sites that offer wrong advise on oral health. Even dental professional offer wrong advise. Here’s one example about advise against the use of toothpick

The sharp surface area might destroy the polish of the tooth, damage the gums or perhaps create the voids in between the teeth to broaden.

A correct technique of any product recommended needs to be established at the dental practice before patient leaves the practice. Toothpick can cause harm to the gum if used incorrectly but so can floss, interdental brush and toothbrushes. I have pointed out two times in this post that the toothpick needs to be the triangle-shaped one if it is used in between the teeth. Never use cocktail sticks!

Also a toothpick should be used only temporarily as it won’t remove all the bacteria from between the teeth for the same reasons as the floss doesn’t. Neither one of them cannot get into the grooves of the teeth (area where the roots start to separate) and the grooves of the fillings.

I will emphasise that a toothpick is perfect in the beginning of the periodontal treatment when the swelling of the gum needs to be reduced.

Finally back to my teacher who advised me to use toothpicks. He was right. Of course he was – he had decades of experience. I was just a cocky rookie in dentistry and thought I knew better.

It wasn’t until I had periodontists as colleagues when I realised that I need to use something else than a floss. My bone level around the teeth was naturally that low that I could fit in a toothpick and later I moved on to the interdental brushes (size 0,7mm). I have used them for over a decade now and haven’t used floss since – and no, I have not developed any decay in the contact point of the tooth.

Have You Read a Poem About Dentistry?

This is a nice read and there will be a poem by Ogden Nash in the end. Worth reading through! Picture and text courtesy of The PB Chronicle.

While I was in Germany, I had the worst toothache. I am not one with perfect teeth, but I had never had a toothache like this. My face was swollen on one side for two days. Luckily, someone who was traveling with me had some medicine that worked and I was fine until I got […]

via The dreaded ‘D’ word — The PB Chronicle

Compilation of Excuses

After being so serious for a while it is time to lighten up for a moment.

People are funny creatures. You can tell all sorts of tales of them and their funny ways. This time I will tell you about people’s creativity when they put a blame on so many other things than their own indolence when it comes to oral hygiene routines.

I’ve collected a list of the answers we get to two of the very common questions we ask. Let’s see if you recognise yourself?

So Are You Using Your Electric Toothbrush?

  • lost in a house move
  • it’s still in an unpacked box after a house move (moved a year ago)
  • out of battery and haven’t got around to charge it
  • it’s malfunctioning
  • can’t find brush heads from the shops
  • I don’t have a plug-in in the toilet
  • it makes me feel dizzy
  • it’s too vigorous.. I’m nervous about loosing a filling
  • dropped it and it broke
  • the manual toothbrush is quicker
  • it takes too long
  • it’s too noisy.. I’m afraid of waking up the kids/wife/neighbour/partner
  • I don’t like the feeling in my head
  • it tickles too much
  • it makes my gums bleed
  • it hurts
  • the bristles feel too hard
  • don’t have batteries in the house (battery operated electric toothbrush)

How About Are You Cleaning Between The Teeth?

  • too difficult
  • too tired
  • floss gets stuck/shreds
  • my gums bleed
  • I lost a filling once
  • it hurts
  • my teeth are so close together that the floss/interdental brush/toothpick is impossible to use
  • I use a mouthwash instead
  • I use the water pick
  • I rinse with water after every meal
  • I use chewing gum
  • my gaps between the teeth are so wide that nothing gets stuck there
  • I push the bristles of the toothbrush between the teeth
  • I use a toothpaste that says it cleans between the teeth
  • I run out of floss/interdental brushes/toothpick (last year) and never got round to buy new ones
  • can’t be bothered
  • it makes the gaps between my teeth wider
  • I don’t have time for it
  • don’t know which one to use
  • is it harmful?
  • is it needed? I never see anything coming out when I floss
  • are you?

Linnanmäki, Finland.

Feel free to add more excuses on the comment box!

 

Profit, Profit And More Profit

Dental Revelations Blog-3559

Do you sometimes feel like screaming after something you read? I do.

I just read a very good article about a new ingredient in toothpaste that will save the teeth of many people. I must say I am normally sceptical about these kinds of releases in the field of dental hygiene products as it is not rocket science when it comes to keeping your teeth healthy. Really!

If you are a healthy individual and you

  1. brush your teeth twice a day with a fluoride toothpaste
  2. clean between the teeth most nights (no-one is perfect – apart from me as I do it meticulously every night)
  3. maintain healthy eating habits (eating 5-6 times per day including the snacks)
  4. don’t drink anything else than water/plain coffee/tea between the meals/snacks

Then you do not get decay. But having said that remember that your teeth won’t suffer from the odd relapse of the routine and good habits. Celebrations, night out, traveling normally mess up the routines and that’s fine. No worries. Your teeth won’t decay because of them as long as you get back to the routines again.

And because it is as simple as this I have found that the news of groundbreaking techniques/bristles in toothbrushes or breakthrough ingredients in toothpastes/mouthwashes are simply ways of marketing for the dental hygiene product manufacturers.

Today it was this toothpaste. With an ingredient that will slowly release calcium, phosphate and fluoride ions. All those that are lost from the enamel of the tooth when we eat or drink something with carbohydrates.

By the way, I never speak about sugar as it is misleading – people tend to think that e.g. bread does not cause decay as it doesn’t have sugar in it (well some do, but you get my point I hope). But it has carbohydrates and if the bread is eaten as a snack many times a day, the bacteria will metabolize the carbohydrates to acid many times a day. And the acids will remove minerals from the enamel of the tooth.

When I began reading the news I said to myself

Just give it a chance… for once just read it through!

And I did. And I found my excitement getting bigger. And bigger. Finally something that might improve the oral hygiene of the ones that are not responsible for decaying of their teeth like children or people suffering from extreme dryness of the mouth.

While I was reading I heard a voice in my head criticizing me for being always so sceptical about the dental hygiene products. I started to think that maybe I have missed something important over the years when I have not given a chance for this sort of news.

But then. I began to read the last sentence:

A fluoride free version of xxxxxx is also being developed for individuals who do not want or need fluoride toothpaste.

Beeeeeeeeeeeeeb.

Somebody-pulled-the-plug-feeling. Then anger.

Once again a new innovation is motivated by profit. Or perhaps there was a genuine desire to find something that would be “The Product” for the sufferers of the decay. But when it became groundbreaking innovation it immediately made it a product with high profit potential. And if you have read my previous post about integrity in dentistry you understand that it is the greed that is orchestrating this release of the toothpaste. No matter how good the initial intentions were.

A Fluoride Free Version? Are You Serious?

I read through many articles about this new ingredient and all of them had one thing in common.

The slow release of fluoride has been identified to be particularly beneficial in prevention of tooth decay.

This sentence in the same article with my previous quote. Do I need to say more? I don’t think so but I will.

I will break down the first quote.

…for individuals who do not want…

Of course there are people who do not want to use fluoride toothpaste. I have written about them in my another previous post Anti-Patients.  But these are the ones who need our guidance in this matter. What they don’t need is another sign from the dental professionals that it is ok to use a fluoride free toothpaste. When it is not.

…for individuals who do not… … need to use fluoride toothpaste.

Excuse me? Do they mean the people who have dentures or mouth full of implants and no teeth at all? They must have as I haven’t met any individual with natural teeth who do not need fluoride toothpaste. But then again if they have meant these people with dentures and implants why would they use this toothpaste anyway?

Conclusion

I am just simply and utterly annoyed and ashamed of the motives of some of the dental professionals. With just one sentence that is spreading in the internet fast and far they made lives of good and honest dentists, hygienists and nurses more difficult when they try to convince patients to use fluoride toothpaste.

The toothpaste manufacturers must be now competing bitterly to get their new toothpaste with this groundbreaking ingredient in the market first. The one that wins this competition is the one that probably paid the most to the company that developed this ingredient.

You would think that they would make enough money just by making fluoride toothpaste as majority of people do use it. But that is so very typical for dentistry – to squeeze out every dollar/pound/euro (or whatever) you can from an opportunity.

Money, profit, creed. A triangle of shame.

When will there be a dental hygiene product line that looks out the consumer’s best interest and is based on the advices of dental professionals? Effective enough electric toothbrush, soap-free fluoride toothpaste (soap is there just for because people think the foam makes it more effective), effective floss and interdental brushes (well there is already one of both, click here to find out which). In the past and currently there are dental hygiene products that are made for what patient’s are looking for

  • a cheap electric toothbrush (battery operated)
  • toothpaste that will deal with all the problems in mouth in one go and it makes mouth full of foam too
  • good tasting and easy to use floss/tape in a fancy looking package

This confuses the consumers as all these products are advertised as if they were very effective. They are not effective in cleaning the teeth and they are just big companies’ way of maximising the profit when they reach all the needs of all different types of people.

I am tempted to write little bit about new models of the manual toothbrushes that the manufacturers bring out every year with massive advertisement campaigns. I am amused every time I see toothbrush ad on tv. It’s just a manual toothbrush for god’s sake. How much can you do developing for it? It has a handle and bristles. That’s all.


Here’s a link to one of the articles about this new ingredient (for those who do not know what on earth I am on about).

 

Don’t Let Just Anyone Touch Your Occlusion

Dental Revelations Blog-3878

Grinding or clenching of the teeth is a very common problem. It is a nasty problem for its bearer as it causes pain in the muscles and in the jaw joint, headache, toothache and even disturbed sleep at night. If nothing is done to the problem the teeth will eventually suffer from the grinding especially if the occlusion is imbalanced. There will be a recession in the gum, worn enamel, chipped enamel and periodontal problems to start with.

So if you do know that you grind or clench your teeth at night – or even more so if you clench your teeth during the day which is a definite sign that you do it also at night – go to see your dentist. But here’s an important advice:

Do not go to see just any dentist. Find a specialist in prosthodontics and stomatognathic physiology (even better if one has a PhD).

Why? I will tell you the reasons from my own experience.

My First Mouth Guard Or Should I Say Bite Block

I am a dental professional and in my early career I was quite naive and thought that all the dentist can do all the stuff they are taught at school. I was so wrong.

In my first year after graduation I had a bite guard made by a regular dentist in my practice. I soon realised it wasn’t perfect and sought help from a specialist in prosthodontics who was working in our practice.

The first thing the specialist did was that he filed away about 0,7 cm (0,28 inches) of the hight of the bite guard without fitting it in the middle of the filing. Once he was done with the filing he started to adjust it to my occlusion. He was covered with acrylic dust and he did lots of eye rolling and head shaking.

He told me that the bite guard is not ideal and it would be better to have it redone. I never really used it after that and I carried on suffering from the grinding and clenching of the teeth.

My Second Mouth Guard – When Desperate You Accept Anything

Couple of years later I lived in another country and once again sought help from a dentist for the grinding. She recommended me an anterior night guard (also known as NTI or MCI) which she did routinely for every patient suffering from grinding.

Now I tried to find you a web site that had a photo and impartial info about anterior night guard but wasn’t able to find one. So I took a photo of mine. I must apologise that the device is not in a mint condition anymore. There is my current mouth guard (that I will tell you more about later in this post) in the photo for comparison.

Dental Revelations Blog-2

NTI/MCI/anterior night guard on the left

I felt this anterior night guard – I will call it MCI from now on – relieved the symptoms I had. I was very happy about the dentist and the MCI. Until I spoke to a former colleague of mine, a very good dentist.

He warned me that I was in risk of developing an anterior open bite due to a use of MCI. I did not second guess him once he explained the reasons.

With MCI the back teeth do not make contact. And when the teeth don’t make a contact with the opposite side they will erupt while the front teeth are kept in place by MCI. The overerupted back teeth cause the open bite in the front. Simple as that.

We’ve all seen what happens to a tooth that lacks an opposing partner in occlusion. It overerupts!

So I got an advice to use the MCI for 2 weeks and then keep 2 weeks break to avoid the overerupting back teeth. So I did. But it did not keep the symptoms of grinding at bay.

My Third Mouth Guard Was Almost What It Should Be

Five years later I was back in my home country where I was advised to have a mouth guard done by a dentist in my practice. I did and she removed my upper wisdom teeth so that it was easier to have the mouth guard done. Once I received the mouth guard I didn’t feel it was helping me at all.

At this point I had had enough of the dentists in this matter and decided to see a specialist in prosthodontics. One that was known to be a good one.

The specialist did a careful examination on my teeth and the mouth guard. He said the mouth guard was ok’ish and that he just needed to adjust it. I also showed him my MCI which he advised to use only as emergency basis and only 4-5 days in a row.

I told to the specialist that I have a feeling that only my last molars were in contact. He checked it and said there was no imbalance – meaning that my bite was as it should be. I also asked if I should do the exercise for the jaw muscles. The specialist said there is no benefit of it.

I had to return to see the specialist every 6 months and every time he adjusted the mouth guard and charged quite a lot even compared to the specialist’s fares.

After 3 years of using the mouth guard there was a hole in it. I had apparently “bitten” through it. It was time to have a new mouthguard done.

My Fourth And Current Mouth Guard

For one reason or another I did not completely trust the specialist I had been seeing so I asked for recommendations of specialists from my colleagues. Based on the recommendations I went to see a specialist in prosthodontics and stomatognathic physiology – she had PhD too!

I was kinda shy when mentioning that I have a feeling that only my last molars were in contact – well hell yeah, one specialist had told me I was imagining things.

Only this time I was told I was right. She also told me that I have a partial anterior open bite. I was flabbergasted. I knew that not all the dentist master the matters of occlusion but even the specialists get it wrong!

And once she had done her magic about my occlusion by balancing it I felt the difference immediately.

By the way – my intact upper wisdom teeth were unnecessarily removed by the dentist who made my third mouth guard. A mouth guard can be done with the wisdom teeth in place as long as they are nicely positioned as mine were.

So after I had my occlusion sorted out I got my new bestest of the best mouth guard. It is amazing I must say. It brought me an immediate relief. But I was only half way through the treatment.

I was booked to see a dental hygienist who did massage for the muscles of the jaw in 3 separate visits and gave instructions (based on the specialist’s recommendations) on how to exercise the muscles by stretching and strengthening them. I realised that having a mouth guard is not enough. It won’t take away the root cause of the grinding which in my case was the weak muscles that did not support the jaw.

The MCI I was not allowed to use again. I did not argue with that.

Conclusion

I, a dental professional had three mouth guards (including the MCI) done until I got a proper one. None of the dentists I saw for the mouth guard had a clue about occlusion or what is the best treatment for it. The second specialist was only concentrating on the mouth guard and did not find the imbalance in my bite. Naughty naughty. I guess he was concentrating in money making – I sense these things as I am HSP – and that was probably one reason I didn’t go back to see him.

I worry over the patients who do not have an understanding of what is right treatment for grinding and clenching of the teeth. There are lots of people using MCI every night and they have been using it for years and years. Do they realise that the open bite they have developed is caused by the use of MCI? No they don’t as the dentist won’t necessarily tell them – especially if the patient is seeing the same dentist who recommended the MCI (see my previous post about this phenomenon). And it is not guaranteed that another dentist will tell either.

Also very commonly the treatment dentists offer for the grinding is the mouth guard. And only the mouth guard. But that is never enough! The best thing any dentist can do for the patient who is suffering from the grinding is to REFER to a specialist.

Important information for the patients: You can make a self referral to a specialist by simply booking an appointment. They will not say no to the new patients. Be prepared to pay more for the mouth guard but it is money well spent.

The occlusion is a delicate thing. I always advice patients not to let just anyone adjust the bite. It can go from bad to worse. You are in better hands when seeing a specialist in prosthodontics and stomatognathic physiology. The higher educated one the better – in any health matter.

I learned my lesson the hard way. I suffered from the grinding for many years. I lost two intact wisdom teeth unnecessarily. And I can’t help but think that the malocclusion on my back teeth and the partial anterior open bite were caused by the MCI. There was a dreadful moment when the specialist was thinking that I might need crowns for my intact canine teeth to fix the open bite and to get enough support for the side movements of the jaw. So I can count myself as lucky that the malocclusion could be fixed by simply filing the teeth.

Phew!


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How Clean Are Your Hands?

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I used to work with a very talented oral and maxillofacial surgeon who did not accept just any nurse to be his assistant. The reason for this was that he wanted absolute aseptic environment for the implant surgeries he was performing. In his words

“One either has an aseptic consciousness or doesn’t. It cannot be taught.”

At that time I thought he was exaggerating but I have learned since that he was actually right.

Simplified, the aseptic conscious is an ability to know when surface, instrument, hand is contaminated by bacteria and how and in which order you start to fix it to make it asepsis. It is an ability to know where you can touch without contaminating the gloves when you are treating a patient. It is the key for effective cross infection control in dental practices.

We learn asepsis at dental schools. But there are things you cannot learn by just reading from the book. Sometimes even practice won’t teach us. In my experience aseptic conscious is as hard to learn as singing. If you do not have the gift you will not become a successful singer (the one’s singing in the shower do not count in this comparison!).

Failing in Basics

A dentist puts her face mask on, washes her hands and puts the gloves on. She gets closer to the patient, adjusts her face mask and uses her little finger to move her hanging fringe to the side of her head…

Err, what went wrong? Pretty much everything after putting the gloves on.

Not understanding what contaminates the clean areas/instruments/hands is a major problem in dentistry. It applies to all the dental professionals – not only the dentists. Even bigger problem is that it is also a subject amongst dental professionals that is hard to bring up if you see a colleague doing something that compromises the cross infection control.

But we must speak about it! How else would they learn asepsis?

Clean Hands

Washing hands needs to be done correctly for it to be effective. But washing hands can be replaced by the use of disinfection gel if the hands are not visibly contaminated. But this needs a correct technique too.

All the professional’s should watch this video about washing hands and using the disinfection gel. I bet many of us fail in the technique.

I must point out that in this video they apply far to little of disinfection gel – if you have an automatic dispenser like the ones the hospitals have, trust the amount the dispenser gives you even if it feels too much.

Also in this video they begin the use of disinfection gel in wrong order. The correct technique goes like this:

  1. Take the gel to the palm of your left hand (or the right, it doesn’t matter from which hand you start)
  2. Dip the finger tips of your right hand in the gel on your balm
  3. Pour the gel to the palm of the right hand
  4. Dip the left hand’s finger tips in the gel
  5. Only then start to spread the gel as advised in the video

Important to remember: Never try to speed up the evaporation of the disinfection gel by waving your hands in the air. This will only contaminate your hands with airborne pathogens.

Revelations

Too many of us professionals fail in either disinfecting the hands or keeping them uncontaminated during the treatments. To prove my point I will tell you my observations.

I have seen

  • dentist removing temporarily his face mask during the treatment to speak to the patient and placing it back again (the same mask and the same gloves) before continuing the treatment
  • dentist using the mirror handle’s tip to press computer keyboard key’s in the middle of the treatment
  • dentist touching the water tap (especially when adjusting dentures/bite block to rinse the apparatus) with the gloves he’s entering patient’s mouth
  • dentists, hygienists and nurses to reach instruments/materials inside the surgery cupboard with gloves that are contaminated by patient’s saliva
  • dentists removing their glove from one hand in the middle of the treatment to do something “aseptically” and then placing the same glove back again
  • dentists removing both of their gloves in the middle of the treatment to do something “aseptically” and then placing the same gloves back again
  • dentists using disinfection gel for the gloves
  • nurses having long and polished nails – I mean reeeally long
  • dentists, hygienists, nurses wearing watches and bracelets

Thank god dental surgeries are pretty much paperless nowadays. The dentists used to check the dental records in the middle of the treatment with the same gloves as they were treating the patient.

Conclusion

A Dentist, hygienist or nurse with pathogen-free hands is every patient’s right to have.

So do pay attention how you get ready for the treatment with each patient. Sometimes we are behind schedule and we cut corners but with this matter you simply cannot.

I will end this post by an information on how all the dental professionals should get ready for the patient (in every day dentistry) and hope you will follow this advise already tomorrow.

Before the treatment:

  1. disinfection gel (or hand wash if visibly contaminated hands)
  2. face mask and eye protection
  3. disinfection gel
  4. gloves

After the treatment:

  1. Remove the gloves
  2. disinfection gel
  3. remove the face mask and eye protection
  4. disinfection gel

Wild West of the Home Whitening

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Oh dear, where to begin.

The reason I chose this topic for my next post is that I was reading a dental blog that gave homemade teeth whitening tips to people. I’m sure the intention was good when they listed all known household items than can whiten the teeth. You see people love to get self help tips on their health – especially on their teeth to avoid seeing the dentist. But dental professionals should know better not to advice certain things as they can very quickly cause permanent damage to the teeth.

(This is a reminder for all of us not to believe everything you read from the net especially regarding your health)

Stains

There are two types of stains on your teeth. Surface stains and deep stains.

Surface stains build up from coffee, tea, red wine, smoking and certain spices, mouthwashes and vitamin supplements (iron in a liquid form).

Deep stains are those that will make the natural colour of your teeth (which you will see after scale and polish when the surface stains have been removed) yellower. The older you get the yellower the teeth will get (or have you seen elderly people with pearly white teeth? If you have they are false).

So what will damage your teeth? I will tell you. Starting from the worst. But at first for clarification

  • I will not give any instructions on how to use these substances
  • it won’t be a comprehensive list of the substances that is adviced to use for teeth whitening purposes but a list of most common ones

Lemon

Would you love to get white teeth with practically no money spent at all (as you get the lemons anyway for cooking etc) plus super sensitive teeth and eroded enamel to go with the deal? Yes? Use lemon.

An advice to use lemon for teeth whitening isn’t under any circumstance acceptable by a dental professional. Lemon is highly acidic fruit and can erode the teeth when used regularly. Erosion will result in sensitive teeth. Imagine if you already have thinned enamel for any reason and you start to use lemon for whitening purposes. You will soon find out it wasn’t a wise move as your teeth will become so sensitive to the cold that even breathing through your mouth hurts. Also the thin enamel will make you more prone to decay.

In 2005 BBC had to apologise publicly for a lemon tooth whitening tip when one of it’s programmes recommended lemon as a money saver to families. I happened to watch this programme and couldn’t believe what I was seeing. Thank goodness British Dental Health Foundation soon found out about the programme as well and complained to the BBC.

I’m not convinced that the apology reached everyone who watched the programme.

Strawberry and Baking Soda

Now combination of these two used daily for longer period of time will damage your enamel. Baking soda works as abrasive and strawberry as an acid. A very bad combination.

Safe frequency of use is once a week.

Baking Soda

It is slightly abrasive to teeth and can damage the teeth especially if used with vigorous brushing technique.

Do not use baking soda if you have braces. It can soften the glue.

Salt

Salt crystals can scratch the enamel. Make sure to let the salt dissolve in the water before using it (kinda looses the point of using the salt, doesn’t it?).

Hydrogen Peroxide

Hydrogen Peroxide is the only known substance that removes deep stains. It doesn’t remove the surface stains so a scale and polish is normally needed prior to the whitening.

There are products over the counter (OTC) that contains hydrogen peroxide but these should be used under a supervision of a dentist as the excessive use of hydrogen peroxide will weaken the enamel.

After Words

If you cause damage to your enamel by these abrasive or acidic home whitening products, it will be permanent. Thin enamel not only make the teeth sensitive to cold and prone to decay but it also makes the teeth look darker in colour. The dentin under the enamel is more yellow than the enamel and it will start to show through when the enamel gets thinner.

Important facts to remember

  • you can never ever change the natural colour of your tooth by lemon, baking soda, strawberry, whitening toothpastes etc. You may be able to remove the stains from the surface of the tooth but not the actual colour that is different with every individual
  • you should never replace fluoride toothpaste with any of the above means. Thinning of the enamel together with lack of fluoride will speed up sensitivity and decaying
  • all the means of whitening the teeth will result in damage of the enamel at certain level
  • any of the whitening products do not whiten fillings or crowns
  • the surface stains will carry on building up after the whitening if you carry on smoking and drinking coffee/tea/red wine. Also the new whitened natural colour of your teeth (whitened by hydrogen peroxide) will little by little get more yellow for the same lifestyle reasons

An impartial information about the risks of teeth whitening is almost impossible to find. The internet is full of practices advertising themselves and saying it’s all fine and dandy to do the whitening. So be cautious!

If you are interested in reading reliable article click here.