How do you floss under a retainer?

March 14, 2016 By Trish Walraven 17 Comments

It used to be such a dread, seeing patients with fixed lingual retainers. I mean, they’re great because they keep your teeth from shifting after you’ve had braces, but GAWRSH, do they have to be so difficult to floss around?

Not any more.

Thanks to the talented hygienists over at Hygiene Edge we now can share this super-easy secret with patients as well!

Here’s how you do it:

It’s embarrassing to say this, but it took me over 20 years as a dental hygienist to find out about this trick, so now I’m thrilled to see lingual retainers on patients because it gives me a chance to share this newfound secret. That’s why I’m sharing it here, too. And as for you poor folks whose retainers are glued to each and every front tooth? I’m sorry, this trick doesn’t work. You’ll just have to stick it to ’em instead:

Remember, it’s all about friction. Whatever gets in there is good by me.

A blogger since 1997, Trish Walraven, RDH, BSDH is a mom and practicing dental hygienist in the suburbs of Dallas, Texas. Her mission with DentalBuzz is to offer a fresh podium of discourse for those involved in dentistry and to expose fun in our professional lives.

A hygienist’s answer to “what do you do?”

March 11, 2015 By DentalBuzz Staff 8 Comments

If you read Dentaltown Magazine, you may have received the edited, paper version of this article today in your snail mail box. But because I don’t have to make room for saliva ejector advertisements in the sidebar (seriously, this article helps sell SALIVA EJECTORS!) you can enjoy the original here in its more raw form.

A hygienist’s answer to “What do you do?”

by Trish Walraven RDH, BS

You’re at a gathering of acquaintances, a general hob-nobbery of casual conversing, one of those social obligations that you love/hate because you’re really more of an outgoing introvert, someone who plays well with others but enjoys their quiet, navel-gazing world too. Sooner or later you know that the question will be asked.

“So, what do you do?”

No hesitation here. You know what your profession is. You have a title, a position, a calling.

Then that inner part of your thinking begins to twitch.

You weren’t asked about your job title, actually. You were asked a direct question: What do you do?

The typical reaction of hearing that you’re a dentist or hygienist involves a full disregard of the art and compassion that you put into your profession. People want to tell you about their bad experiences as a child, or how much they hate you (but don’t take it personally!). They just nod, warily, quietly, at your response and quickly think of a way to change the subject.

Instead of giving away the conversation and letting it slide into other people’s thought bubbles, then, you can steer the dialogue back to the original question, and the feel-good answer you’ve prepared instead.

“I take care of people’s teeth.”

You’re a regular Mother Theresa now, aren’t you? The way you dedicate your life’s work to helping others, it’s so freaking noble. This response elicits a smile of comfort and familiarity from your obligatory small-talk partner. The conversation can move forward now that your profession has been deemed socially acceptable.

An hour later, driving home, you’re blissfully alone with your thoughts, rewinding your earlier social interactivity, musing over the highlights, and you really, deeply, ask yourself in hindsight, “what do I do?”

I can’t speak for dentists, but if you’re a dental hygienist, you do some pretty strange things, actually.

First of all, perfection to you is wave-shaped. It’s the curve of a thin scallop of attached pinkness that anoints each interproximal space with a coral-tipped point of the healthiest gingiva imaginable. Anything less than this in your patients’ mouths is limbo. Chaos is the reason your job exists, but you always hunger for order and balance. To achieve this imagined perfection in a mouth that is not optimal, then, means that you often resort to some diversions along the way. It’s about the journey, not the destination, right?

How do you handle the patient whose lower anterior linguals are piled with a couple of grams of Grade A calcium phosphate? Sure, you could just chunk the calculus off. But sometimes, when you’re feeling a little dastardly, you carve out the top and the bottom of the tartar evenly, so that you’ve left a neat chalky white mustache, complete with curlicues. With artistic satisfaction, you turn your attention back to your duty and politely erase the Banksy-esque dental graffiti from your patient’s teeth.

This is not something you tell people that you do.

You also tell no one that your deepest fear is running into anything artificial while you’re cleaning someone’s teeth. Your ultrasonic scaler turns into a fierce lead pencil in those situations, which means not only that you are wearing down your precious metal antennae into useless nubs, but also that you’re leaving dark lines where there was once only whiteness. Every last bit of old orthodontic cement has now been revealed like a charcoal rubbing, thanks to you. And you would never admit to leaving a grey streak on a brand new porcelain crown. How could you slip like that? You hope like heck that the prophy paste will get that scary line off before anyone notices.

When it comes to things that you enjoy, then, there’s a bit of hesitation about sharing those stories as well. Like hovering around the periapical abcess that’s begging to be relieved? Or when you’re spraying baking soda slurry under a bridge and the patient becomes aware that its odor speaks more than the thousand words that you could ever say about superfloss? To you the stink is like scoring a point. Or why your trophy at the end of a particularly difficult appointment is a 2×2 gauze loaded with something that looks like buckshot, but is really your patient’s carefully extracted calculus? Fun times.

Probably the most difficult part of your career, though, has to do with patient management. Unless you’re regularly disengaging people from their mouths via nitrous oxide, there are forceful tongues, and lip pulls, and saliva ropes, and people who forget that it’s safe to swallow their own spit. Suck. Suck. Suck. Ten times a minute. At least this way they’re remembering to breathe. When they forget to breathe they feel like they are drowning. It’s not the water; they’re just suffocating because you’re blocking any chance of mouth breathing. Never mind that noses are much more optimal for breathing but whatever. Not everyone has learned how to snorkel either. And how do you convince patients that unless they just ate a handful of almonds, brushing immediately before their dental appointment won’t make your task any easier?

Then there are the patients themselves. Not just their mouths, but the whole person. Patients whose embarrassment about their teeth are the reason they haven’t been to a dentist in a while. People who not only open their mouths but open up to you, tell you their secrets, their fears, their wishes and hopes. People who trust you to take care of them, to love them, to nurture them towards health. They see something special in your eyes, and they open wide.

So go ahead and make it known out there in the big world that you’re hygienist. Or a dentist. You scale teeth. You drill teeth. No biggie. That’s what you do.

What really matters, though, are the reasons why.

Trish Walraven RDH, BSDH is a mom and practicing dental hygienist in the suburbs of Dallas, Texas. She is a bit of an an introvert when she’s writing dental articles, but you get her together with her best friend from high school and Irish festival beer and she begins to make faces like this. She also makes faces like this under her mask if her patients aren’t paying attention to her flossing instructions.

*dentist not included (with clear aligners)

September 26, 2014 By Trish Walraven 147 Comments

This post is from the time when SmileDirectClub first began its marketing campaign, from the standpoint of a general dentist’s practice, and the feelings of whether or not online-ordered cosmetic aligners would be taking away market share for dentists. The reviews are posted below the article, from those who have used the product or who have questions about it. The company declared bankruptcy in 2023. Way to take the money and run!

If you’re not an orthodontist, but you straighten teeth in your dental practice, I’ve got a fistfight just waiting for you. Where? Thankfully someone else went through the trouble of making this cute little scroll-ey infographic, so I’ll just post it here and save myself the trouble, and the punches.

SmileCareClub Wants to Disrupt Dentists- Crowdfunding Insider (no longer available)

(sorry, looks like the infographic wasn’t sanctioned by Smile Care Club… anyways, here’s another link on IndieGogo)

A full set of dental aligners, just like the Invisalign® ones, for a third of the cost or less, can you simply order them online? With no visit to a dental office? Heck, why not? I mean, all you have to do is worm two pieces of putty together and then squish them onto your teeth for an impression, mail them to the lab, upload a few photos from your smartphone, and wait for your trays to magically appear at your doorstep.

What is it with blue boxes? Is blue, like, a confident color or something? See how the SmileCareClub box compares to an aligner box from our office:

And then there’s the involvement of the aligner-providing dentist. The ClinCheck inclusion is a facade, a joke? You mean to tell me that the lab could do all of this via 3D imaging and just cut the middleman dentists out of the deal?

Not completely. You’ve got interproximal reductions that still need to be managed in some cases, and the SmileDirectClub is looking for ~~suckers~~ Endorsed Local Providers to saw those big fat teeth into submission. And who the heck knows whatever happened to attachments? I personally had Invisalign attachments placed a decade ago, and cannot imagine what my results would have been without them.

Orthodontists are probably chuckling to themselves. They saw this coming with all of the cosmetic tooth straightening programs being marketed to general dentists over the last decade.

It makes the whole teeth whitening mall kiosk issue seem petty, now, doesn’t it?

SmileCareClub doesn’t appear to have a single dentist on its management team, but they employ a few, I guess, to keep it legal, I guess. It’s really hard to tell. This aligner system is also sold on the Sharper Image website, in case you want to forward a link to any patients who look at you sideways and curse under their breath when you tell them what their in-office aligner treatment is going to cost. Sharper Image– that’s legit, right? Maybe you didn’t realize that the original Sharper Image went bankrupt. Interestingly, the brand name was bought by the same VCs that, guess what?- own SmileDirectClub.

Orthodontists, are you feeling disrupted yet?

I didn’t think so.

A blogger since 1997, Trish Walraven, RDH, BSDH is a practicing dental hygienist and marketing manager for an indie dental software development company. Her mission with DentalBuzz is to offer a fresh podium of discourse for those involved in dentistry and to expose fun in our professional lives.

2015 Update:

SmileCare Club is now called SmileDirectClub, which you can see at SmileDirectClub.com. The cost is $1500, and if you Buy Today!, they’ll include GloScience gel (interestingly enough, here’s what DentalBuzz had to say about GloScience in 2011).

Aug 2016 Update:

Invisalign has announced that they are building aligners for Smile Direct Club. See the notice in the comments below. The similarity of the boxes now makes sense!

2017 Update:

Invisalign now owns a 19% interest in SmileDirectClub. But that kind of backing will cost you $350 more, which now brings the cost of aligner therapy to $1850.

September 2019 Update

Smile Direct Club just had their IPO, and now the founders are billionaires. It’s all about disruption of the status quo, apparently, because if you can afford $80/month instead of $150/month (the cost to see a real orthodontist) you should Do Orthodontics Yourself. Smile Direct Club have no more than 250 dentists that “check” the cases. That’s one dentist per 3000 patients (750,000 people served so far)! Bottom Line? If you think of teeth as ornaments, not functional body parts, then that’s on you if they rot out or you can’t chew with them afterwards. Story here: https://www.bloomberg.com/news/articles/2019-09-13/smiledirectclub-s-ipo-creates-a-pair-of-30-year-old-billionaires

October 2023 Update

Melissa Busch, Dr. Bicuspid.com

Clear aligner company SmileDirectClub filed for voluntary protection under Chapter 11 of the U.S. Bankruptcy Code on September 29 in the U.S. Bankruptcy Court for the Southern District of Texas, according to a company press release.

The bankruptcy comes on the heels of recent legal pitfalls involving SmileDirectClub. In August, a California court confirmed an order requiring the orthodontics company to pay $63 million to Align Technology, a former partner and the maker of Invisalign, over a supply agreement dispute. SmileDirectClub had planned to appeal the decision.

In June, SmileDirectClub settled a suit with the Washington, DC, attorney general’s office, which claimed the company made injured and dissatisfied customers sign nondisclosure agreements (NDAs) to receive refunds for their clear aligner therapy. Under the terms of the settlement, SmileDirectClub was required to release 17,000 U.S. consumers from provisions in its NDAs. Also, the company had to change its refund policy, notify consumers who previously signed NDAs that they could now freely speak about their experiences, and stop forcing people to sign NDAs that prevented information sharing before refunds were provided.

December 2023 Update

The SmileDirectClub website is gone. You’ll find this message there instead:

Customer FAQ

SmileDirectClub has made the incredibly difficult decision to wind down its global operations, effective immediately. For new customers interested in SmileDirectClub services, thank you for your interest, but aligner treatment is no longer available through our telehealth platform. For existing customers, we apologize for the inconvenience, but customer care support is no longer available. Thank you for your support and letting us improve over 2 million smiles and lives.

I placed an order for SmileDirectClub aligners, but have not yet received my aligners. What should I do?
Unfortunately aligner treatment is no longer available through the SmileDirectClub platform. All orders that have not yet shipped have been cancelled at this time, and you will not receive your aligners.

Should I continue to conduct my 60-day check-ins? Is my treating doctor still available to complete my treatment?
We apologize for the inconvenience, but aligner treatment is no longer available through the SmileDirectClub platform. If you wish to continue treatment outside of our platform, please consult your treating doctor or your local dentist with any questions around future aligner treatment.

I’m on the SmilePay Plan. Do I need to keep paying for my aligners?
HFD is the service provider for your SmilePay payment plan. For questions regarding your financial obligations please contact HFD at 1-877-874-3877, [email protected] or visit their website at www.gohfd.com/.

Is the Lifetime Guarantee still in place?
No. Effective immediately the Lifetime Smile Guarantee no longer exists.

How do I ask for a refund?
There will be more information to come once the bankruptcy process determines next steps and additional measures customers can take.

March 2026 Update

There will be no more updates – this is because the video below that was posted last week follows the timeline above perfectly. As a plus, it’s a well-researched bit of journalism, with all sorts of behind-the-scenes tidbits about what was really going on in the minds of the founders. I heard that the class settlement was paying out about $75 per patient that did complete treatment, so am hopeful that those who did not complete their treatment were compensated better.

SmileDirectClub: The $8.9 Billion Scam That Ruined Smiles

If you were compensated otherwise, had to sign a Non-Disclosure Agreement (NDA), or anything else that still doesn’t sit right with you – please feel free to compare notes with others in the comments below.

Is Arestin® a red flag?

September 5, 2014 By Trish Walraven 70 Comments

Not long ago, all dental practices were owned by the dentist who took care of you. Sure, they might not have given you any anesthetic before they smashed silver crunchy metal into your cavities, and they may have slapped you around and given you Post Traumatic Stress Disorder any time you thought about opening your mouth wide for anyone, but at least you knew that the dentist shoving their knuckles into your nostrils was the one dictating how things were done around there.

Since then, dentistry has gone all Wal-Mart on the public. There are thousands of dental offices that are part of large chains, where the dentists who take care of you are merely employees, where the quality of dental care provided to patients is secondary and instead the amount of profit generated by each provider becomes the indication of that person’s worth within the company. Can you imagine a leaderboard, like in a sales department, where all the dentists’ production numbers are on display for the entire office, so it’s a race to see who can make the most money?

As a patient, don’t you get giddy at the thought of being ridden like a thoroughbred horse? Me neither. My health is not a commodity.

Dentistry is a little different creature than regular medicine in the sense that TEETH ARE OPTIONAL. You can be a very healthy individual, only with no teeth. It’s kind of like having a hand amputated – your quality of life may be affected, but a hopelessly infected hand should be removed and replaced with a prosthetic. If your body is rejecting your teeth for whatever reason, that’s when there are health concerns as well. Dental professionals make it their life’s work to help you keep your teeth in as close to original condition as possible.

The problem is that when money is involved, you can bet that there are those who will abuse this relationship. There’s scare tactics, there’s bait-and-switch, there’s all the usual sleazy sales pressure used to extract as much income from each patient as possible. New patients often bring us treatment plans that they are unsure of, looking for second opinions, trying to figure out why they don’t trust the previous dental offices’ diagnoses. I just want to say it straight, “They’re taking you for a ride, dear.”

Whip. Whip.

Well crud, I never wanted this article to be an analogy of horse racing with the big hats and Bourbon and milk-drinking and jockeys. So, let’s start over and begin talking instead about Red Flags and Grey Areas.

Red flags, of course, are the signals you get when you realize something that seems good, isn’t so good. Red flags are big fat warning signs.

Grey areas, are, well, not really black and not really white. Grey areas are where black and white kind of blur into each other, and sometimes they end up looking a little suggestive (!) like the image above. Yeah, sorry about how weird that looks when I take it out of context.

When it comes to the health of your mouth we usually look at two things: your teeth, and the stuff that holds your teeth in your mouth. That’s what we’re going to talk about in this discussion, what you think of as your gums. Dental professionals call this part of you your periodontium. If your gums are in excellent condition, you have what is called periodontal health. On the other hand, if your gums are seriously letting go of your teeth you have periodontal disease.

As you can see, the biggest part of this diagram is the Grey Area. This is where most people land, especially if they haven’t been to the dentist in a while. Even if your front teeth are mostly healthy often you’re automatically categorized into the Very Diseased category because you have too many spots in your mouth that are infected with bacteria to treat you as a Very Healthy person. That’s when you’ll get a treatment plan designed to minimize the effects of your disease.

When your mouth is in the Grey Area, this is where treatment recommendations can vary the most from office to office and even from person to person. Almost every dentist will prescribe the same treatment course if your case is black and white (very diseased or very healthy). If you’re in the Grey Area though, this is when Red Flags will start to stick out.

There’s one Red Flag in particular that keeps showing up. Arestin® is a yellow powder containing minocycline microspheres – an antibiotic designed to help diseased gums heal faster. The powder is puffed deep into an infected spot under the gumline where it hardens upon contact with moisture and time-releases the antibiotic for about three weeks. Here’s what the package of cartridges looks like, with the yellow powder in the tip:

Arestin is a great product! I’ve seen stubborn gum disease completely disappear when we’ve used it very selectively in our practice. So the Arestin itself isn’t a problem. The problem is how it’s being prescribed.

Say you had your gum disease treated with scaling and root planing (a “Deep Cleaning”), but a few spots are still unhealthy a month or two or three later. If your dentist or hygienist sees that you still have open sores that are higher than a certain parameter (over 4mm is considered the standard) this is when Arestin therapy provides the most benefit.

So when is Arestin a Red Flag? You’ve visited a new dental office, and not only are they recommending that you have treatment for your periodontal disease, they’re also saying you need a course of Arestin to be placed on the same day that you have your initial treatment. It’s even a bigger red flag if you floss regularly and never see your gums bleed.

The thing is, Arestin isn’t cheap. Just a single cartridge costs your dentist upwards of $15. Then there is the insertion fee; in other words, what the patient is billed for placement, and than can run as much as $60 per site.

Here’s where it gets crazy. An average mouth has 28 teeth. Each of your teeth has as many as six sites where Arestin can be placed. Let’s see, that’s $90 in material costs, $360 in placement costs. That’s potentially going to cost you $450 – per tooth.

You’re seeing the big picture now: treating gum disease can be quite profitable! This is why Arestin is such a big deal in the offices that are part of corporate dental chains designed for maximum shareholder profit. This antibiotic is marketed to dental professionals as a way to help us make money, all in the name of “helping our patients.”

So how do you end up getting prescribed Arestin therapy if your mouth is pretty healthy? If your hygienist or dentist was instructed to “force the probe” to create a deep measurement, that’s how. Stab ’em hard and voila! Fake gum disease! Here’s a story that exposes some of the bad things that have allegedly happened in corporate dentistry, including this example:

http://www.pbs.org/dentalworks-chain-misdiagnosed-for-money-dentists-say/

As you can see, lots of other stuff can be exaggerated as well to make sure that the dentistry performed on you is as profitable as possible. For now, though, we’ll stick to talking about the Red Flag, because this one cue may help you decide whether or not you’re being over treated.

Here are the professionally accepted general guidelines about Arestin usage, then:

Now please don’t use this to go and bash your well-meaning dentist and hygienist, or the Arestin company, or worst of all, to justify the reasons you tell yourself why you don’t go to the dentist ’cause it’s all one big scam and you can’t trust anyone. Most of us really do want the best for you.

The point is simply this: if more people understand the difference between dental care that is patient-centered and dental care that is profit-centered, then greedy dental corporations are less likely to thrive.

If you think you have ever had this happen to you, I wrote this story for you. For you, so that you don’t feel so dumbfounded the next time you wonder whether or not a dental office is looking out for your health or only for their own. As a hygienist who knows fraud when I see it, I wanted to be sure that patients have a resource to help them defend themselves against predatory practices.

I’d like to end this with a small confession, then: I actually love placing Arestin, because when the dentist and I decide that it’s a good fit for a stubborn case of gum disease, it just feels so right.

So much for being objective.

References and resources:

Explanation of insurance coding of Arestin therapy after initial SRP: http://www.practicebooster.com

An example of Arestin-based fraud in a DHMO: http://caldentalplans.org/downloads/Henderson.pdf

Arestin drug label and study that shows slight improvement of using Arestin with SRP vs. SRP alone: http://dailymed.nlm.nih.gov/arestin

Criticism of Arestin studies and concerns about Arestin therapy : http://periodontist.org/is-arestin-a-therapeutic-treatment-for-reducing-gum-pockets/

I wanna be sedated

July 28, 2014 By DentalBuzz Staff 3 Comments

By Amanda Kaestner

Oh yeah, that’s all we need.

Back in 2006, a research psychiatrist at the National Center for Post-traumatic Stress Disorder, H. Stefan Bracha, M.D., suggested upsetting dental experiences could install PTSD in patients, which might then last their entire lives. Along with another couple of miscreants, Bracha advised that any caption including the word “phobia,” or “anxiety,” wasn’t humorless enough to describe the unfounded fear of our selfless, albeit remarkably remunerative, healing art.

What, then, is it exactly that sends our patients into states comparable with returning warriors who’ve experienced an imminent threat of death on the battlefield?

Thanks Again, Sir Larry

Well, patients who are edging onto the chair for an invasive procedure, obviously enough, are more fearful than those who’re scheduled for a cleaning (though we’ve all seen hygienists who seem determined to even out that particular playing field).

Assuming the dentist is warm and caring, rather than emulating Sir Larry, better known as Laurence Olivier’s character Christian Szell in 1976’s Marathon Man, the single most intimidating factor may well be unconsciousness. When you’re out, you’re unable to inhibit a negative event or experience. It’s not so much that patients expect us to slip ’em a roofie and wreak havoc with their innocence, it’s just that – in all fairness – being utterly helpless is an intimidating event for most animals. It’s lack of control… it’s…

Sedation and Anesthesia

Choose your poison. Of the several methods of dentistry sedation that ensure reciprocity on the recliner, each has its proponents, but most have problems, too.

Local Anesthesia. The injection of local anesthetic directly into the area where the work’s to be carried out; this blocks nerve impulses, thus moderating or eliminating pain signals. But it’s the jab, man. The. Jab. That needle heading inbound at their head is, for many patients, the very image which sets off their trip-hammering heart. Not nice.

Inhalation Sedation. Nitrous oxide/oxygen is a great deal of fun at frat parties, sure. It has its place in our surgeries, also, after the light-headedness and giggles give way to euphoria and sleepiness. Improperly administered, though, adverse effects can range from vertigo and nausea, through active vomiting to hallucinations and unexpected flash-backs (and couldn’t we expect that to bring on driver lawsuits, were the fact widely known).

Intravenous General Anesthesia. Voila! The Cadillac of the comatose. An intravenous (IV) catheter is inserted into a vein and from there, an infinitely-controllable amount of anesthetic happiness is introduced. Just a few good drips and the patient is in a safe state of unconsciousness, allowing the professionals to get to work without any major side effects after all procedures are said and done. To the patient’s benefit, there’s no sensation of pain at all, and no memory exists afterward of the entire time he or she was “under.” More and more practices are looking to this form of sedation as being their one and only form because it’s just that safe, comforting, and effective. For example, Advance Dentistry, a well-known practice in Cincinnati, has found that IV sedation helps the dentist because it reduces the risk of movement, and it provides maximum comfort (or minimal discomfort, I suppose) to the patient no matter how much work he or she may need done. It’s not uncommon to see IV sedation being their primary option for dental anesthesia. Furthermore, recovery from this form of anesthesia is typically swift and complete, with little or no “hangover” effect as one would see in the other forms listed earlier, so the patient’s free access to their credit card is seldom impacted.

We’ve come a long way since the early 19th century where anesthesia wasn’t even a thing in any surgical practices, much less dentistry. But thanks to Horace Wells first introducing nitrous oxide to his procedures back in 1845, we can honestly say that going to the dentist in today’s world really isn’t that scary of a thing. So look at your options when you go to the dentist and ask about other forms of sedation. It’s a far cry from “pass the liquor and bite down hard on this stick and let’s hope we don’t have to amputate anything from aftermath infection.”