Today I Saw My One in a Thousand Patient

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A-mazing. Simply amazing. That is what I thought when I took a look at one of my patient’s mouth today. It wasn’t something I expected to happen after interviewing the patient.

You see amongst many other things I always ask the patient if he uses fluoride toothpaste. This patient didn’t. And the reason for not using fluoride was a fear of the side effects and the fact that he has never had decay. He was 36 years old. I was sceptical of course. I was certain what I was going to find. If you have read my post Anti-Patients you know what it is. If you haven’t and you are about to click the link, do scroll down to the paragraph Anti-Fuoride when you get there.

So today I was certain that I was going to find decay. At least the early stages of it. Or dental erosion. And I was prepared to go through the routine of informing the patient about the consequences of not using the fluoride toothpaste.

But. A big but. The teeth were in immaculate condition. No plaque, only tiny amount of tartar and definitely no decay. No matter how hard I tried to find even the smallest evidence of it – of the patient being fool not to use fluoride. But he was no fool. Far from it. He had good eating and oral hygiene habits and he attended the dentist regularly. That made him very wise.

Both me and the patient had the same question in our minds. Why isn’t there a toothpaste which contains only calcium for the patients like this one. They don’t need fluoride. Would calcium be enough? But then again, do they need toothpaste at all?

And for those not using the fluoride toothpaste by choice, remember that it really is one in a thousand that will get away with it. Most people will get problems with decay or dental erosion.

 

 

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Eeny Meeny Miny Moe – Which Type of Tooth Wear?

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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Don’t Let Just Anyone Touch Your Occlusion

Dental Erosion and Tea

 

Superiority of the Philips Sonicare Toothbrush

Dental Revelations Blog-4586

Philips Sonicare forever!

I used to be brainwashed by one of the biggest electric toothbrush manufacturers and thought that there is no better toothbrush than these round-headed ones. I was so stuck in this illusion that I didn’t even give another toothbrush a chance to be better.

But then I moved to another country where two of the biggest toothbrush brands were almost equally popular compared to my country of origin where this manufacturer with round-headed toothbrush was and is dominating the markets.

In my new country of residence I was offered a free trial of the Philips Sonicare. I was amused by the looks of it (it was the old model) and thought it wouldn’t be a very good toothbrush. I almost declined the free trial because I was so convinced about the superiority of this round-headed toothbrush.

But then I gave it a go. It was ticklish as hell at first but thankfully my colleague dentist had warned me about it. I carried on using it for the full two minutes. Once I was done I got my moment of awakening.  My teeth had never felt better. So smooth, so clean.

Patient Case

I was treating a lady – lets call her Sue – at her early twenties for severe gum disease. She had already had periodontist treatment and understood the severity of the situation considering her young age. Sue was very motivated to look after her teeth and did everything she was advised to do.

Sue had a surface retained glass fibre reinforced periodontal splints (everStick®PERIO) on her lower and upper teeth. She was using Tepe interdental brushes of various sizes twice a day and an electric toothbrush – the round head one. She changed the brush heads every month (even though she was informed it was necessary every 3 months). Her brushing technique was checked many times and it was perfect.

But every time I saw Sue for the 4-monthly scale and polish she had supragingival (visible) calculus on her lower front teeth. Lots of it. And she started to be very distressed about it because she was doing all the right things to prevent it. I tried to ease her worry and told that the supragingival calculus was not a problem gum wise as long as it was removed regularly. And in her case the gum didn’t even get inflamed by the presence of supragingival calculus. But it did not calm her mind. She didn’t like the looks of it as it was clearly visible when she smiled.

I had no idea what to advice more than I already had. She had all the right tools – interdental brushes and a latest model of an electric toothbrush. She used them often enough and with a correct technique.

Then I thought about Philips Sonicare I was using. I suggested to Sue that she could change her toothbrush. I expressed my frustration over the fact that she had spent quite a lot of money for the current toothbrush but this was all I could think of that might help her. I showed her the correct technique of the Sonicare just in case she followed my advice.20181104_152933.jpg

Next time Sue came in she had a wide smile on her face when she entered my surgery. She said the calculus had not built up at all! Sue had gone straight to the shop after the last visit and bought the Philips Sonicare toothbrush. She was very happy and thankful for the advice I had given.

This was even more of an eye opener for me than my own first experience with Philips Sonicare.

Why Is It Better?

The name says it all. It’s because of the sonic vibration. When used correctly the sonic vibration can reach beyond the bristles as the sonic vibration travels through the liquids in mouth.

People who think Sonicare is not a good toothbrush have not used it with a correct technique.

I have noticed in the past 15 years of using the Sonicare that I and my patients who us it, get less stains. Hardly any even though I drink coffee and tea.

Conclusion

In my country where I live and work now, the Philips Sonicare toothbrush is not very widely used or recommended by the dental professionals. I am considered as odd one out when I tell I use one. And even stranger it seems that I recommend it to some of my patients. Almost as if I didn’t know my business.

In the dental show case I didn’t even find a representative of Philips Sonicare from any stands. And I cannot find any contact details for a rep to invite her to my practice or to express my views over their marketing strategy. You see the marketing is very poor compared to their competitor who has given trial models to my practise with disposable brush heads so that the patient can be shown the correct technique etc. They give out free electric toothbrushes to the professionals (I have written about it on my previous post) and visit practices regularly to promote their products.

But thankfully the Philips Sonicare toothbrush is available in the shops. And I am doing a small-scale marketing for them. My hope is that they would take more aggressive approach to the almost non-existing marketing. I could even go to the next show case as their representative just to annoy the rep of their competitor who told me that the Philips Sonicare is as effective as manual toothbrush (you can read about it here).

It would definitely make my work easier when convincing the patients about the superiority of the Philips Sonicare toothbrush. And perhaps my colleagues will start to recommend it too.

Here are couple of models of Philips Sonicare electric toothbrush:

Basic model with 31000 brushstrokes per minute (don’t buy anything lower than 31000)

The flagship model with 31000 brushstrokes per minute