Operative Dentistry

Were these third molars aborted?

May 22, 2013 By Trish Walraven Leave a Comment

It looks like wisdom teeth can be preventable.

Now that you’ve found yourself a little incensed at the inflammatory title of this blog post (sometimes it takes alarm words to grab people’s eyeballs these days!) you’ll realize that the word ABORT actually does apply in this case.

Last month Tufts University School of Dental Medicine announced that there was a correlation between the injection of local anesthesia given to children between the ages of two and six and evidence of missing lower wisdom teeth. In other words, if a child had an IAN block at this age, they were over 4 times more likely to have missing third molar buds when radiographs were taken at least three years later.

At this young age, the cells that will become the third molar are not much larger than the anesthetic needle itself, and the developing tooth bud is quite vulnerable to injury. Dr. Anthony Silvestri, a clinical professor at Tufts University and an author of this study, has also published research to support the trauma theory of wisdom tooth prevention, showing that both diode lasers and electrosurgical energy can stop third molars from developing in rats.

Interestingly enough, I might have been affected by this phenomenon. As a kid I had my share of mandibular blocks as soon as my permanent molars started popping in with occlusal decay, and never developed my lower wisdom teeth. Thank you, Dr. Big-Scary-Hands-But-Really-Nice-Dentist Tom Watson DDS! Thank you for excusing my future visit to the oral surgeon.

You know, if the science behind this prophylactic de-nucleation of third molars gains any momentum, think about the consequences. In the next thirty years out-of-work oral surgeons will be lining up in protest of the loss of their bread and butter business. They’ll be picketing general dentists who perform these euphemisms and call them names like wizzie abortionists or bud killers.

Don’t take a side just yet. At this point the ethics of new research itself are even in question, but if there is a way to inoculate kids against the inconvenience of such minor diseases as chicken pox and shingles, why shouldn’t we at least explore the idea of making third molar extraction an option instead of an inevitability for most people?

And as a hygienist trying to hit production goals, I say, well, there goes my fourth qualifying tooth for quadrant scaling and root planing.

Thanks to these articles for all their information:

TuftsNow: Dental Anesthesia May Interrupt Development of Wisdom Teeth in Children
Nerve Blocks in Children May Destroy Future Molars
Dimensions of Dental Hygiene: Local Anesthesia and Wisdom Teeth Development

Future “drug” for dental phobics

April 12, 2013 By Trish Walraven 2 Comments

It looks like virtual reality may actually be almost Matrix-quality in a few short years, and our patients will be able to immerse themselves fully in another world while they’re getting their dental work done. But because there’s a lot more money to be made in gaming (and there’s a MUCH wider customer base) don’t expect that this technology will have a dental application any time soon. Here’s a decent introduction to the concept featuring Palmer Luckey, the originator of the Oculus Rift headset:

These sorts of glasses have been intriguing to me for years, but all the previous versions mentioned here on DentalBuzz basically make it seem like you’re watching a TV screen from a distance. Oculus Rift is different. Users have described the feeling as being totally disconnected from reality. And isn’t that what recreational drugs do? Isn’t that what dental sedatives do?

Imagine a dental appointment where a fearful patient is allowed to slip into a virtual playground where they don’t even need to move their head much in order to initiate the immersive feeling of being elsewhere while they hold their totally oblivious mouths open. Patients’ ears will hear the sounds of their “other world,” letting them slip away from their bodies for a little while so that you can manage all the dental unpleasantries for them.

Here’s another preview of Oculus Rift:

There are many software developers in dentistry that are in search of the next big thing. The 3-D milling technology is pretty awesome these days, but indirect dental software such as patient education, practice management and the like are also looking for the leg-up. Oculus Rift is looking for developers right now, and my guess is that they haven’t even imagined its application in dentistry.

But that’s because you haven’t yet picked up their development kit to make it happen.

Here ya go, and good luck:

Why your fingers shouldn’t be in the picture

March 15, 2013 By Trish Walraven 7 Comments

“Just this once; it’s okay.”

Does that sound like your practice? You know, you have a gaggy, bouncy kid who’s just about to tongue-thrust their way out of having those radiographs taken, but here comes Amazing Assistant to help you get a diagnostically acceptable image. SCORE!

The problem is that this never happens “just once.” I’ve seen the same person holding sensors in patients’ mouths dozens of times, and that’s when it becomes a problem. Yes, radiation is safer now that we’ve dialed it down and collimators make sure that there’s nothing scattering beyond the focused beam, but that doesn’t mean that we should be flippant about limiting exposure to our patients and most importantly, ourselves.

My best friend from high school could tell you not to hold those films in people’s mouths, too. She was a dental technician in the Navy and also worked for years in pediatric dental offices and orthodontics as an assistant, calming nervous children, helping them to have good dental experiences, and when she was exposing radiographs, sometimes she admits that she would make it easier on everyone if she would stay with the child while the x-rays were beaming through her hand.

She doesn’t have to tell you not to hold the films, though. She can just show you why you shouldn’t:

This is her right hand. Several years ago when she was doing laundry her finger caught on the dryer and “snapped.” This is important, sort of like when your patient tells you exactly what they were eating when their tooth broke – don’t you pay that the most attention of all? Because it was the darn dryer that was the problem….(!) Let’s be serious, though. Like you, her doctor really didn’t care what broke her finger, he wanted to know why it broke.

Turns out that she had developed a giant cell tumor in the first (proximal) phalange of her ring finger that had eaten everything except a small sliver of bone and that was what had snapped. These are very, very rare in small bones like those found in our fingers; most osteoclastomas happen in the larger bones like femurs and such. Hmmm.

Even though the tumor was benign, because of the damage done, the possibility of regrowth and other factors, the decision was made for my friend to have her ring finger amputated. I would have had her flip you the bird for effect but she no longer has a middle finger either…! (think about it…!)

So she was fortunate enough to stay in dentistry as a patient care coordinator for a few more years as she recovered but is now working towards her master’s degree for speech pathology. While she doesn’t seem totally convinced that excessive radiation exposure caused her to lose her finger, she doesn’t count it out for even a second.

And neither do I.

Losing a finger may be anecdotal evidence about the dangers of radiation, but it’s enough for me to feel like enforcing what we already know to be true.

Please share this story with those you care about, even if it makes you feel like the Radiation Nazi.

A plea to use DMG Icon infiltrant

February 22, 2013 By Trish Walraven 9 Comments

Don’t you think that this is the WORST part of orthodontia? You take off the brackets and voila! Straight teeth… with fugly white squares where acid beat the $#!† out your patients’ anteriors. And NOW you have to go drill on their teeth, destroying what you so carefully tried to perfect.

Once you’re here there’s no use in blaming the patient; it’s not like they’re going to get the brackets put back on to cover the white spots and then get more decalcification there. Yes, you should help them with their lifestyle choices (less energy drinks and voluntary mouth breathing, please) but at this point you have to do something to make them look better.

As a hygienist I’ve been totally itching for about the last four years to get the go-ahead to use a relatively new product called an infiltrant. There’s only one, it’s made by DMG and it’s called Icon. This infiltrant is placed on the tooth where it seeps into smooth-surface lesions that haven’t fully cavitated (although if you ask me the ones in the “Before” picture above look way gnarled out) and pretty much does a little remineralization voodoo.

I’d hoped that it would be classified as a sealant because Yay! I can do sealants. There’s no drilling done, right? There’s nothing taken away, right? There is, however, some irreversible improvement made to the tooth though and that (plus a significant etch time) means that when the CDT recognized that an infiltrant needed a code, where did that boom fall? Smack dab into Composite Land as a D2990. I know. The wording says “placement of an infiltrating resin restoration for strengthening, stabilizing and/or limiting progression of the lesion” and that SCREAMS prevention. Alas there’s the other word. Restoration.

Dangit.

Another problem is that this stuff is very expensive. See what it costs here for the mini kit for a maximum of six lesions?

That’s at best, $27 per tooth just for the kit (not including your other overhead or minusing the limited-time Amex card!). The suggested cost to a patient should be somewhere between your one surface composite fee and a sealant fee, and conservatively it takes at least 20 minutes of intense doctor time to place an infiltrant on a single tooth. Composites don’t cost that much or take that long to place so you know what that means, right? THE FEASIBILITY OF ICON SUCKS.

I really hope I’m wrong, but to most doctors, what’s a few millimeters of drilled-away tooth structure? Minimally invasive dentistry is for anal retentive freak dentists anyway. And every hygienist who has ever had a passion for preserving tooth structure, including me.

So yeah, this is bad news for Icon and for DMG, really. Sure, they got a CDT code this year but it’s not like anyone is going to use it. There’s like one dentist in a 5o mile radius that’s even ordered it around here. I know this because you can look on the DMG patient portal here and find a dentist that offers Icon in your area.

I have a challenge then. Actually two challenges – one for dentists, and the other for those who want to see this service added to the hygienist’s scope of practice in every state.

•If you’re a dentist and you love saving teeth, JUST DO THIS. Charge what you must, you’re not going to get rich, but you will have the warm fuzzy feeling that you’re doing the right thing by preserving tooth structure. We all know composites and amalgams eventually fail around their margins. There are no margins with an infiltration, just a lovely, arrested half-moon where an incipient lesion never progressed if you follow up with radiographs two decades from now (I may be exaggerating, but maybe not!). Go here, learn more, buy some.

•Those of you who are frustrated with dental hygienists wanting to become these mid-level providers that are supposed to help in low-access areas but will probably just come take your job away from you (I keed! I keed!) please support the use of infiltrants by hygienists. You will still need to diagnose that the treatment is needed but the service should be able to be delegated because of the very nature of the care being provided and the labor intensity needed for this smaller ROI.

As a realist, I don’t see squat happening as a result of this challenge. What can one blogger do? I have these silly dream glasses, when I put them on and see the future, well, there are no more cavities, on anyone, except arrested ones, and all the dentists are happy because all they have to do is play on the computer and nod their head every so often while their hygienists prevent all dental infirmities for ever and ever. Then I take them off again, and I see white spot lesions on teeth.

And I say…..dangit.

Thanks to Dental Products Report and The Catapult Group for this review of ICON from DMG America: http://www.dentalproductsreport.com/dental/article/review-catapult-group-delves-details-icon-dmg-america

Iraqi vets losing their teeth

February 12, 2013 By Trish Walraven 4 Comments

Our local ABC affiliate ran an investigative story on TV today that made me think I was in the middle of a big CE lecture with blown-up pink on the edges and all white and brown in the centers. Dental closeups! Yeah, I should probably put a porn-type filter on my email box when those “identify this lesion” photos pop up because they are just so gross to look at when I’m not in my Dental Frame Of Mind.

I saw three severely decayed mouths in super-close detail on local television, and felt sorry for everyone eating lunch during their noon hour that caught the show, too.

The gist is that these men were serving in Iraq almost ten years ago and now all their teeth are rotting and breaking and hurting and the VA won’t pay to get them fixed up.

As much as you want to feel bad for these guys, and I do, there’s a big part of me wondering what questions aren’t being asked. They’ve never done meth, they don’t complain about severe dry mouth. That’s about all the evidence I heard. What about medications that may be causing an acid imbalance in their saliva? What are their soda habits? How well did they keep up with their dental care the first five years since Iraq?

Watch this video, or if you just want to get through this quickly and avoid an orthodontic commercial, go read the transcript here.

The station will be airing another segment tonight so I may post it online tomorrow that may answer some of these questions and get to the bottom of this Medical Mystery and our pathetic excuse of a government that lets this happen to innocent people (not necessarily my view, but possibly the witch that this investigative report is trying to hunt down).

I’d love to know your theories too, post them here, maybe we can all figure this out together with our Holmesian powers of deduction and ultimately solve this conundrum for these unfortunate men.

Update:

Here’s the second segment of this story (Go Dr. Beadle!) where stress is cited as a major factor in causing tooth loss. I guess it could, in a roundabout way. You’ll find the transcript of this story here, for those of you who aren’t in the mood for a movie.

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