Tag: dentistry

Repost with Forewords: Alcohol – The Feared Subject

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Acute pancreatitis is life threatening illness

Today I went to see a man who for my children is very dear despite his dependency to alcohol. They never defined him as an addict and never thought anything but the best of him. This man is their grandfather who fell gravely ill several months ago with acute pancreatitis caused by lifelong abuse of alcohol.

Having spent over five months in hospital of which he spent four in an intensive care (2 months in coma), he was finally at home. But he was a shadow of a man he used to be.

This man used to be proud. He was a kind and pleasant (when sober) man. He was very skilled and was ready to help others when needed. He loved kids and knew what would make them happy.

Today when I went to see him he was lying in bed barely recognisable weighing just 50 kg. He had tubes coming out of his stomach leading into a bag that was filling up with brownish secretion from his organs that were riddled with a spreading necrosis. He was unable to obtain any food or drink inside, taking several medications many times a day, dependent of his wife who was looking after him. His voice was like he was speaking from the grave.

It was the saddest sight I have ever seen. There was no need or desire to say I told you so. No gloating over being right all these years about his future. It was just simple sadness over a kind man, father, husband, grandfather who would have had so much more to give to so many but instead now was bed-bound waiting the imminent death. Slow death that took away all pride and dignity and which every day reminded him why he is where he is now. Alcohol.

But even more sad than seeing him now is the fact that he never got the help he would have needed for his drinking which started at his twenties. No-one intervened when there was still a chance to turn the tables. Instead of this a troubled sensitive soul was taken over by the numbing comfort of an alcohol that took a firmer hold of him as the years went by. He faced many misfortunes in his life and he dealt with them by alcohol. He had happy times and he dealt with them by alcohol. Before he reached his fifties everything he did, everywhere he went the alcohol came along.

He was told by all the close relatives that he cannot continue drinking like this. He was told he has a problem with the alcohol. One day he admitted he does, the other he declined. He never seeked help. And no-one could force him. Instead he came a master in finding excuses to visit his hidden bottle. Taking the garbage out, checking something from the garage, fetching firewood for the fireplace. Everyone who was witnessing this knew that he went for his hidden bottle. This too was heartbreaking to watch.

When he finally fell ill and the house needed to be emptied of all the alcohol there was altogether 30 litres of strong spirit.

This man’s story is not unique. There are plenty of similar fates in the world.

The longer the alcoholic carries on drinking the harder it is to intervene. I mean that the intervention we can do at the dental practice has less impact than it would have in the early days of an addiction. That is why the early intervention is very important and us dental professionals have a very easy and natural way to intervene.

Please read my post below and hopefully it will bring you courage to ask about patients’ alcohol consumption.

About 60 year-old man came to see me one morning and complained that every once in a while a layer of skin comes off inside his mouth and no-one has been able to tell why. He was concerned and felt…

Source: Alcohol – The feared subject

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Not Truly Gone

Eeny Meeny Miny Moe – Which Type of Tooth Wear?

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Dental Revelations Blog-3877

There are four types of tooth wear that we diagnose from patients’ mouths. Erosion, abrasion (I’m sorry for a missing link – I did not agree with any of the images of abrasion), abfraction and attrition. The easiest ones from these to diagnose are the erosion and attrition. You can’t go wrong with them. But it is completely different case with abfraction and abrasion.

When a dentist or a hygienist sees tooth wear on the neck of the tooth they diagnose it by default as abrasion caused by too vigorous brushing. If there are also receding gums on the same teeth as where the tooth wear is, the dentist makes a wrong conclusion easily. They recommend softer toothbrush and this silly brushing technique called Bass (it is so silly that I think I am going to dedicate one post entirely to this technique).

This normally leads into a situation where patient begins to be too careful with the brushing because she doesn’t want to cause further damage to the teeth. That’s when the plaque starts to build up to the gum line, gum gets inflamed because of the plaque and the patient begins to notice bleeding when brushing. Now she’s even more careful with the brushing as in her mind bleeding means she’s doing something wrong – brushing too hard like the dentist said she is. She’s afraid that the bleeding means her gums are receding.

But what if the dentist/hygienist misdiagnosed the tooth wear? What if the correct diagnosis was the abfraction?

Tooth wear – What to Check?

When you see a tooth wear that you are tempted to diagnose as abrasion, stop for a moment before you proceed giving advice on brushing. Instead do the following:

1. Check if there is mobility on the teeth affected by tooth wear

2. Check if there are interferences on side movements and protrusion

3. Check if there are shiny facets on occluding surfaces

4. Check if the gums have receded on affected sites.

If you get positive answer to even one question the chances are great for the tooth wear to be an abfraction. And in this case telling patient that the tooth wear is caused by her brushing can be damaging in many ways:

  1. It is hard to convince a patient that they are not actually brushing too hard and that they have not damaged their teeth by it. I have my ways of convincing the patient but life would be soooo much easier if I didn’t have to.
  2. The dentin will decay very easily (as I’m sure you know) and plaque accumulating and staying there undisturbed for longer period of time because of too careful brushing will very quickly cause decay. And we all know that these fillings in the cervical area can be pain in the butt. Somehow they always seem to have overhangs or they come off when scaling. Sound familiar?
  3. The teeth where the surface of the root (dentin) has been exposed by receding gums will get sensitive if the plaque builds up.
  4. If the tooth is mobile and has already bone loss the plaque building up to the gum line and inflaming the gum can be disastrous. Please memorise that

MOBILITY + PLAQUE = RAPID BONE LOSS

The Cause for Abfraction Needs to Be Dealt With

When a tooth interferes with full closure, it will trigger deflective interferences6-8 and cause any of the 7 signs and symptoms of occlusal disease such as hypersensitivity, abfractions, mobility, excessive wear or fractures, and muscle or temporomandibular (TM) pain.

There is no consensus amongst the dental professionals over the right approach to occlusion. Is this the reason why signs of interferences on occlusion are ignored or unchecked and the tooth wear is so easily made as patient’s fault?

The quote above is from an article The Three Golden Rules of Occlusion in dentistrytoday.com and you can read a full article here.

But by Whom?

To be honest – and like I have expressed in my previous post – I would not let just anyone touch my occlusion. I would love if the dentists would refer patients to the specialist in prosthodontics because they have the best knowledge and skills to treat the occlusion. And that’s something every patient is entitled to.

Guilt Is a Heavy Load to Carry

I have often noticed that patient feel unnecessarily guilty over damaging their teeth. They feel guilty and desperate over the fact that the damage done by brushing is irreversible. And that they are not sure if their brushing technique is still damaging their teeth hence too careful brushing to make sure they are not.

I believe that guilt does not lead us forward in life, it does not bring anything positive into our lives. Therefore I always try to relieve my patient’s guilt whenever it is possible.

In the case of tooth wear and some dental professionals way of putting the blame on patients’ brushing technique I always have the same conversation with a patient. It goes like this.

Me: Have you been told that you brush too hard?
Patient: Yes I have.
Me: I thought you might have. You see when a patient is told this, she starts to be too careful and then the plaque starts to build up and there is actually plaque in the gum line of your teeth. (I take a mirror and show the plaque to the patient)
Patient: Eww..
Me: I personally try not to tell patients that they are brushing too hard because this leads to too careful brushing which will cause more problems like decaying and gingivitis. Instead I interview the patients about how they brush their teeth and correct it if necessary. You see the tooth wear can be caused by other things than just vigorous brushing… 

Prior to this conversation – in the beginning of the treatment – I have interviewed the patient and asked about her oral hygiene habits. Which brush she uses? How often? How often does she replace the brush head/brush? How does the brush head look like before replacing it? Spread or still like new apart from colour fading? This is why I can continue the above conversation like this.

Me: In your case I doubt it that the tooth wear is caused by your brushing but I will just in case show you the right technique. I will first just check couple of things…

And then I check the mobility, the interferences and the occluding surfaces. I feel great satisfaction when the teeth affected by tooth wear have mobility on the side movements. I am on the right path!

The patient is visibly relieved when they can stop worrying about their brushing. Well who wouldn’t be! There is enough to worry about in life even without worry over brushing.

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Ever Seen a Patient with an Implant? Read This!

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Dental Revelations Blog-4621

Today I saw a patient who had had an implant done to replace upper right first molar. The implant treatment was finished a year ago in another practice.

Since then the patient had seen hygienist twice in my practice. The implant crown itself looked immaculate but the gum was very red and puffy and it bled heavily after probing.

I knew what to ask next and I even knew the patient’s reply to this.

“Were you told how to clean the implant at home?”

“No I wasn’t” replied the patient with is-it-supposed-to-be-cleaned-expression on his face.

This happens too often. Almost every time I see a patient who has recently had an implant done.

Note for all the dental professionals who make the implant treatment’s final stages and do not give oral hygiene instructions (OHI) for the patient:

You should always tell and show how the patient can clean these costly pieces of metal and porcelain. It is your responsibility as a dental professional and the paying patient’s right!

Can you give me any other excuse for not giving OHI than the fact that you are too busy making money and forgetting the basics? I believe you cannot.

And you hygienists who see patients with implants:

  1. Always check how the patient is cleaning them. More so if the gum around the implant is either bleeding or there is plaque around it
  2. Advice if necessary and show in their mouth how it is done
  3. Check if the patient understood your instructions by asking them to show they can do it. Teach them if they struggle
  4. Check on a follow-up visit that the gum has healed. If not, refer to a dentist

Why Is It So Important?

With the implants it is vital that there is no bleeding in the surrounding gum. They will get an implant’s equivalent to gingivitis – peri-implant mucositis which can lead to the peri-implantitis (same as periodontitis with teeth) very rapidly. The worst case scenario is that the implant will lose its integration to the bone which could have been easily prevented.

The patient I saw today left home with instructions on how to look after his implant. And I will see him for a follow-up visit to make sure the gum has healed (can you see the shining halo around my head?).

Honestly, it’s not that hard to do your job properly so shape up please!

Here‘s further reading on the subject.