CBCT 3D Imaging

Technology in dentistry, like technology in general falls under a few categories.  Some innovations allow us to do things quicker and more predictably.  A great example of this is our Isolight system that we sometimes use to help with suction and giving you something to rest your jaw on instead of having to stay open.  Some technologies allow things to be done faster, but not necessarily better.  Offices that offer crowns in a day have jumped onto this technology.  CEREC crowns are becoming a popular option in many offices due to the fact they eliminate the temporary crown stage and having your definitive crown placed the same day the tooth is worked on.  This technology is one we haven't adopted yet and doesn't improve the final crown (there are definitely plusses and minuses to the system).  Another type of technology is one that allows us to do things we have not been able to do before in our office.  We are very excited to be adding a Cone Beam CT (CBCT) scanner to our office.

What is CBCT?

A CBCT machine is a 3D imaging system that captures data by rotating around the patient and taking images then reconstructs these to form a 3D representation of the patient’s teeth and jaws.
The radiation level from a dental CBCT scan is very low, and significantly lower than medical type CT scans.  CBCT scans do not replace the need for traditional x-rays and you may never need a scan.  

Uses of CBCT in Dentistry

The volume of data we get from this technology allows for a wealth of possibilities in terms of diagnosis and treatment. Some of the uses we’re most excited about:

• Diagnosis of infection/source of discomfort- Traditional radiographs are limited by two dimensions.  We have been bound by films that are burdened with overlapping structures, distortion and lack of comfort.  
• Implant Placement- 3D imaging allows us to know much more accurately where the bone is compared to a 2D image.  By having a representation that is this accurate, we can combine with other models and impressions and have guided surgery for implant placement.  This is the dental equivalent of endoscopic surgery.  Many times we can place these implants without any need for sutures and very minimal post op recovery.

Adding the right technology at the right time...

For diagnosing cavities and periodontal (gum and bone disease), our digital radiographs that we have been taking are still top of the line and you will continue to receive these films as needed.  Many of our patients will not need a 3D scan.  However, those patients who have missing teeth and are interested in implants, patients who have had those "phantom" pains that have not been able to be visualized on 2D imaging, those needing extractions, especially of wisdom teeth and those who have had numerous root canals that haven't felt right you may find use of the new technology we are STOKED to be adding to our practice.  By allowing use to see what we would otherwise be unable to see, by allowing us to limit complications by knowing and utilizing what information was hidden and by having at our hands the power to show and teach by having a model and image that people can see and understand we are convinced in the power of this technology.

Do I really need to floss?

“Do I really need to floss?”

Unfortunately, I have heard this question more this month than I probably ever had.  I get it.  Flossing isn’t sexy.  It takes time when we can hardly find time to brush our teeth.   Sometimes it gets splatter on the mirror.

This month an article came out from the Associated Press stating the government has done little high quality research to prove flossing works.  A good scientific study is done over a long period of time, is well documented and has a control group.  Studies that lack these are considered to have lower validity. 

If we were jumping out of plane, most of us would feel a lot safer with a parachute.  We KNOW that with the parachute we will have a much greater chance of a nice landing.  If we wanted to have a scientific study that was good, we would have a control group that was jumping without a parachute to so we could compare between the outcomes of the two groups.  Ideally the people jumping out of the plane would have no idea if they have a real parachute to a placebo bag on their back.  Are you ready to partake in this study?  The government has no high quality research that a parachute works!

On big issue with the studies that are done with flossing are that most have involved patients who report back that they do floss daily.  How reliable are we when we have to self-report anything?  Do you think our children are any better at this?  I know when I was asked as a kid if I flossed I always told my mom that I had.  I probably didn’t brush all the time either.  At least not as often as I say I did.  One question I always ask younger kids is how often they brush their teeth every day.  The most common answer is “yes.”  After that I probably get the answer “100,” followed by “5.”  The real answer is almost never one of those. 

Another issue with the article is the conclusions that were drawn from some studies.  A 2006 study divided kids into three groups.  One group was professionally flossed 5 days a week by a dental professional.  One group flossed only once every three months.  The other group self-reported daily flossing.  This study lasted 18 months.  The results showed that there was no difference in the group that self-flossed and flossed only once every three months.  The group that was professionally flossed 5 days a week had a 40% decrease in the incidence of interproximal dental caries (the fancy term for “flossing cavities” or cavities between the teeth).  The point taken home from the AP study was that there was no difference between not flossing and flossing yourself.  The point I took from the study was proper flossing reduces cavities by 40% and most people do not take the time to floss properly or just say that they floss, when in fact, that may be an embellishment of the truth.

So, do you really need to floss?  Should we wear a parachute? 

It’s your call.  I do, twice daily in fact.  We tell you once daily is effective.  I have no financial interest in Proctor and Gamble.  If you buy truckloads of floss each time you visit Target, I do not get my pockets lined with green.  I tend to be busier when people do not floss.  I invite to take this challenge.  Floss every day for a week, this is even better if you do this after a cleaning.  On that seventh day, smell the floss.  Take a week off of flossing and smell the floss after that and see if you notice a difference.  I have a feeling that while not flossing keeps our schedule a little busier here, not flossing may open up your social calendar some. 

Writing an article telling people that they do not have do something that really don’t like doing is a great way to get some clicks and sell some ad space.  

Children's Dental Health Month

Among other things, February is Children’s Dental Health Month and with my son just celebrating his first birthday this month (that first year goes by so fast) it seems like a good time to write about setting up your child for a lifetime of smiles.

                Parents of little ones are inundated with facts on development.  There are typical dates we tend to see our kids reach certain milestones such as sitting on their own and crawling.  Cutting their first tooth is one of these less exciting times.  Typically, we see the lower front two teeth breaking through the gums between 6-8 months, but this is a range, there isn’t necessarily anything to be worried about if your child gets his first tooth early or late. 

                As guardian of your child’s mouth, your job should begin before you reach this milestone.  Good habits start early.  After feeding, it is never too early to get started on your oral hygiene regimen.  A moist cloth quickly run over and massaging your baby’s gums not only helps clean them but it teaches the more important routine of you working in their mouth before it’s a painful area that they do not want you to touch.   One great product out there is xylitol wipes that helps with this.  I know it’s tough, but it is a little work to save you a lot of headaches later.  

                 Once they get that first tooth though, it is important to get a toothbrush on it. Luckily, there aren’t too many teeth to brush at this point so this is a quick thing to do.  Usually, I let my son watch me brushing my teeth with my electric toothbrush and then I let play around on his own.  After playing two minutes of keep away with my brush he is quick to let me get the brush in his mouth.  It doesn’t have anything other than water on it at this point.

                The ideal time to touch base with a dentist for your child is 6 months after that first tooth has come in.  This first visit isn’t necessarily a cleaning, but a great chance to talk about their oral development and help with parental education.  We are often talking about the need to break the child of their pacifier habit around this age, adding a little toothpaste into the brushing routine (just enough for a little flavor at this point, almost always less than you’d think), and setting up good mealtime habits.  In my office the rule is to make sure the visit is a happy one.  Developing a good relationship with a dentist is important.  We start off on the right foot so we can build to where we need to be.  We typically like to see your child as far away from his most recent pediatrician visit as possible.  It can be a little tough on your child to be in a dental office immediately following an appointment where they just had routine vaccines.  They are skeptical of those in white gloves!

                Until your little one is 5 or 6, they will need help with brushing.  Help will flossing will need to continue until 10.  At this age, you child should have the dexterity to brush by themselves, but they do not always have the compliance they should have.  The earlier it becomes a routine the easier to it will be to transitioning them to being able to do it themselves.  Make sure they are spending a full two minutes, brushing all surfaces of the teeth front and back. 

                Both general dentists and pediatric dentists are fantastic at fixing decay.  Preventing decay from happening starts at home.  Frequent checkups can help prevent big surprises.  If we can find a cavity that is small enough, we can sometimes reverse the process and prevent a filling in the first place.  If the decay goes unchecked we frequently have to deal with early tooth loss. 

                I often tell patients if we can get them to adulthood with no cavities, we can usually keep them that way most of their lives.  The “big ticket” items we usually dread as adults such as crowns, root canals and extractions almost always found on teeth that needing a filling as a kid.  So many complex issues that we work to solve with braces are issues that started because of early tooth loss.  Our baby teeth are the foundation for our oral health the rest of our lives.  

Fourth of July and Summer Dental Tips

On July 4, 1776 one of the most, if not THE most, important document the world has ever seen was adopted by the Second Continental Congress.  By the end of summer, it was signed by fifty six men.  The first to sign was John Hancock, the youngest was Edward Rutledge and the oldest was Benjamin Franklin.

Over 200 years later, we still celebrate the courage of those fifty-six brave men and the Fourth of July has become the pinnacle of summer.  They most likely were not thinking that hamburgers, hot dogs and pool parties would be the end result, but would be proud to see the number of stars on the flag with 13 alternating white and red stripes that would blanket the country on this day. 

The world is a different place.  Our dentures look different than the ones George Washington sported as seen below.  Note that they are not actually made of wood, but ivory, teeth from other people and a number of other things we would not want in our mouth.

There are a number of dental safety steps we all can take to help keep our teeth safe from damage this July 4 and the rest of summer.

The pool is the area we see the most amount of trauma to teeth.  Kids don’t listen when we say not to run on the wet concrete.  Teenagers think it is great fun to launch their bodies from a trampoline to the pool.  Frat boys can one up that and go from the roof or balcony into the water.  Things don’t always go as planned.  Whether it is a fall on the edge of the pool, hitting the bottom of the pool or even just swimming into the side because the chlorine was burning their eyes, teeth can get knocked loose or broken very easily. 

Here are some tips from the Academy of General Dentistry:

Follow these simple first aid steps for a tooth that has been either knocked loose or knocked out:

If a tooth is knocked loose, gently push the tooth back into its original position, bite down so the tooth does not move and call your dentist or visit the emergency room.

For an avulsed (knocked out) tooth, pick up the tooth by the crown, not by the root – handling the root (the part of the tooth below the gum) may damage the cells necessary for bone reattachment. If the tooth cannot be replaced in its socket on site, do not let the tooth dry out. Place it in a container with a lid and use milk or saliva. Visit the dentist as soon as possible – the longer the tooth is out of the mouth, the less likely the tooth will be able to be saved.

Swimming frequently in a pool can lead to increased staining and tartar buildup due to all the chemicals that keep our pools from looking like the local pond.  Make sure you’re keeping up on your regular cleanings to keep gingivitis at bay.

Recent studies have shown girls are more likely to receive concussions playing team sports growing up but are rarely evaluated for them.  Mouth guards have been shown to help prevent heavy impact to the skull in addition to protecting the teeth, but typically we only see football players and people participating in martial arts or boxing to wear them.  There are a lot of organized sports and most of them have at least some physical contact or a ball or puck.  Even if it’s not required, we strongly recommend having a mouth guard made if you or your child is active in sports.

The next two summer recommendations are not that obvious but can have serious complications to your oral health.   First, stay hydrated with water.  Sports drinks are very erosive to the teeth and are as bad as soda or lemonade at attacking our precious enamel.  Once we get dehydrated, we also get dry mouth (xerostomia) and without saliva to rinse our teeth the sugars that are in about everything we eat don’t get naturally cleansed and sit there for the bacteria to eat up and spray out their acid on our teeth.  Second, wear lip balm with some SPF protection.  You lips get roasted out there and typically don’t get the same sunscreen protection we lather on our arms and legs.  Skin cancer is much more common on the lips than it needs to be.  Protect yourself and your loved ones.

Make sure you have fun celebrating the greatest nation of Earth.  Do so safely and I hope some of these tips help keep your mouth a little safer. 

God Bless the United States of America.

Baby Teeth

Many times I see a patient who wants some aesthetic work done and we first try and see how they smile now.  Quite often, I'm told "I don't smile."  Young kids are great because they will smile no matter how their teeth look, but as they get older self-esteem, self-consciousness and other pressures set in.

This same adult who won't smile and has issues with their teeth may also be the one who asks "why are baby teeth important?"  Fortunately, I don't seem to be getting this question as much now as I used to.  I hope we do a good job at educating parents and this is helping.  The question comes in many forms.

"Do we really need to do fillings?  They are just baby teeth."

"Do we really need to fight about flossing and brushing?  They are going to lose them anyway."

The answer is a resounding "YES!"

Baby teeth are just as important as your permanent teeth.  In many ways, they are more important.  The baby teeth do more than just help us chew until we get our full compliment of adult teeth.  Teeth play a huge role in helping us speak.  It's amazing how much a role your teeth play in speaking.  Ask someone who has a denture about how switching from their own teeth to a set of false teeth made them feel like a different person.  Imagine how much harder it can be to adapt while we are just learning how to speak.

The biggest worry I have from parents on a first visit is about braces.  Braces are expensive and they want to know if their kid will need them.  Most kids (and even us adults) could benefit from orthodontics.  We can try and minimize the need and severity but allowing our childrens' jaws to grow to where they need to be to have space for the teeth they will get!  This includes keeping the baby teeth in the mouth to prevent loss of space and eliminating or limiting other factors that hinder healthy growth such as thumb or finger sucking and pacifier use.  Pacifiers have some important early on but past 6-12 months they should be completely eliminated from use.  Our jaw sizes in general are shrinking in society.  Our genetics are not really changing.  Behaviors play a huge role in our growth.

The above picture was the first result I got on Google images searching for a child's smile.  Do the same search yourself and you'll probably get a smile of your own.  Children are developing their sense of self at an early age.  We want them to have every chance to have great self worth.  A healthy smile is happiness.

Baby teeth usually start coming in around 6 months of age.  Shortly after that it is recommended to have a visit with a dentist or pediatric dentist.  Typically, we love to have the first visit be a happy visit and get your child used to being at the dentist before there is an issue.  Letting your child see what a dental chair looks like, pick out a tooth brush and get a sticker or two for doing such a good job is a lot easier than trying to do a filling on a scared two year old.  In my office, we want that first visit to be successful and sometimes we are able to get a cleaning in but sometimes we aren't.  We don't push your kid if we don't need to.  This appointment is more about the parent or caregiver and making sure we get them the tools to keep that smile healthy.  

When your child was born, they already had 20 teeth hiding below their gums.  Their two front teeth (usually lower first, then upper) are the first ones to poke through.  Back teeth tend to do most of the work with chewing, but forming our smile is what nature chose we needed first (much to the dismay of breast-feeding moms everywhere).

By two to two and a half years, we usually see a full set of 20 baby teeth.  However, its the time the first one starts to poke through.  Decay can start anytime sugar or acid comes in contact with tooth.

Here are some tips directly for the American Dental Association.

     *Do not let your baby or toddler fall asleep with a bottle of sugary liquids (this includes juice!!)
     *If your baby needs comfort between regular feedings or at bedtime, give him a clean pacifier.  Never dip a pacifier in sugar or honey

     *Do not put the pacifier in your mouth to clean it and then put it in the baby's mouth.  You may pass on decay-causing bacteria to the baby.

     *Do not allow children to frequently sip sugary liquids from bottles or training cups, since this can also lead to decay.  Even watered-down sugary drinks, including juice, can damage teeth.  

So what can your do to keep your child's mouth and teeth healthy?

     *Wipe the baby's gums with a clean, web gauze or washcloth after feeding.  Its great to get your child used to having you cleaning their mouth.  

     *As soon as that first tooth breaks through the gums, brush it two times a day.  Morning and right before bed.  As soon as there are two teeth that touch.  Floss once a day.  Until your child is six, they will need help with brushing and the dexterity to floss, that typically doesn't come until they are ten.

     *Make sure your child is getting fluoridated water.  Many cities and towns add fluoride to the water in the ideal concentration.  Brentwood does not, but the water is naturally fluoridated pretty close to that level.  If you child doesn't drink tap water, fluoridated bottled water is available.  

     *For children under three, use no more than a smear or grain of rice sized amount of fluoridated toothpaste.  For children three and over, we can increase that amount to a pea sized drop.  

     *Make sure your child is eating a healthy diet.
     *Ask your dentist questions.

Prevention is the best thing we have to keep the smile healthy.  There are ways we can keep teeth in the mouth as long as they are designed to be there, but good habits, having sealants placed on permanent molars once those are erupted and regular dental visits are key to having a smile on your child like the one above and not the one below.  

Dental Insurance Part 2

Took a little bit longer than I anticipated to get to writing this second portion of the bit on insurance.  To rehash, the previous post covered the types of insurance, in-network versus out-of-network coverage and some other basic information.

Now I would like to touch a little on benefits.

Having a particular insurance doesn't mean it covers things the same as another plan on the coverage.  Your specific plan is usually dictated by your employer (if that is who the coverage is through).  Delta Dental, for example, has thousands of plans that are all different.  Sometimes the plans are different for people in the same household.  Many of the plans with Delta Dental are what is referred to as incentive plans.  With these plans, everyone will start out at a base percentage for most procedures and it goes up each year you use it until most procedures are covered at 100%.   If you neglect to use it one year, the coverage usually drops back to the starting level.  We love these plans as they work at keeping you in good shape by keeping you on track with appointments.  Patients sometimes hate having the out of pocket expenses the first 3-4 years of cleanings if they are used to having preventative covered at 100%, but come to love the plans when they don't have an cost to replace that old crown that popped off.

Another time that insurances have different benefits for those in the same family is for things that are age related.  Fluoride is one of the most important supplements we can have to let our teeth develop as strongly as possible.  Everyone who has enamel can benefit with a fluoride treatment.  Some insurances recognize that, but some will say that they will only pay for the benefit up to a certain age. Children are at higher risk of tooth decay because they typically have the worst diets and worst hygiene, but this isn't the case.  Its why insurances in general will pay more for fluoride and more frequent radiographs with children than with adults.

Another thing insurances do that can be tricky is downgrading procedures.  They will say that they will pay a certain percentage of a tooth colored filling or crown, but when the time comes to pay, they will sometimes change it up and downgrade the treatment to the lowest cost alternative treatment.  You may want a tooth colored filling on the front side of the tooth and they insurance company may say you can, but they will only pay the percentage for the silver filling.  This doesn't mean that you can't get the treatment that you want, but it means you will be responsible for the difference between the two types of treatment in addition to your copay.

Worst of all, your insurance company will sometimes request preauthorization for certain procedures and make you wait weeks until they let you know if they will or won't pay for it.  Sometimes they authorize treatment but the fine print says they don't guarantee benefits.

Insurance companies also like to just reject treatment all together, change their PO Box address so it takes longer for them to receive your claim, or request information that they don't typically need in order to keep from paying the claims in a timely manner.  Like any business they are out to make money (Delta Dental is technically a not for profit corporation, but that is more tax status and they make a pretty penny off of all of those insured and have the multimillion dollar CEO just like the rest of them).  If they can keep your money that your premiums paid for a little longer, they make more money off of it.

In short, if you feel like the insurance company is trying to pull the wool over your eyes, they probably are.  They have a number of tricks to make money.  When you are in our office, I like to say there are three people in the room.  Your dentist, you and your insurance.  Two of them care about your dental health.

We are typically very good at providing estimates on treatment and limiting surprises by doing benefit checks before your appointment and trying to preauthorize treatment whenever possible, but sometimes there is no predicting what they will do.  Some insurances won't pay for replacing tooth structure lost because of acid reflux, but will pay if you lost tooth structure by opening beer bottles with your teeth like crazy Uncle Cleatus.  It's maddening.  We are hear to help you understand.

Many insurance companies have great plans and many have really poor plans too.  If you are unhappy with the coverage of your plan, you employer can sometimes get a better one with the same company by just threatening to leave.

Hope this helps understand the mess the insurance industry is in.  It's getting worse with the ACA and government involvement.  Many of the plans through the exchange won't even tell us the benefits until after treatment is done and claims submitted.  It is unreal!

Everything should be as clear as mud now.

Dental Insurance Part 1

The end of the year always has two groups of people in a dental office.  Those with remaining benefits and those waiting until they get new benefits.  
I thought it might be fitting to do a few pieces about dental insurance as best I can and post it here on the blog as a resource for those wanting it.
In the mid-1950s dental insurance came to be.  It was actually a pretty straightforward way to try and increase availability to dental care.  The move was actually led by dental organizations in California, Oregon and Washington and over time became what we call Delta Dental.  Delta Dental has changed over the years and isn't exactly the same organization, but is still the largest insurance carrier for dental benefits.  Especially here in California.

Back when Delta started most plans had an annual maximum of about $1000-$1500 per person per year.  This is when the average cost of a dental crown was about $100.

Here in 2014 there are a seemingly infinite number of plans that are out there and an equally large number of insurance companies.  Funny thing is, most have an annual maximum of about $1000-$1500 per person per year.  (Anyone thing the premiums for these plans have stayed the same?).  For those keeping track at home, the average cost of a crown today is a little over a $1000.  Are we getting the same bang for our buck?

To complicate things further, there are really 3 main types of dental insurance.  

Indemnity Plans are what most people think they have, but very few actually do.  These plans do not have networks.  They pay for services that are performed at set percentages (varies by plan) at a dentist of your choosing.  In most cases, dentists will bill the insurance for you and accept assignment so you pay only your copay and the insurance company will pay the dentist the rest of the fee.

The most common type of plan is the PPO (preferred provider plan).  This plan is similar to the indemnity plan as you do have some choice in who you can have as your dentist.  Some plans are what is called an EPO (exclusive provider option) that companies market as a PPO, but they may not provide any benefits to your chosen dentist.  The PPO plan allows you to choose who you can see, however, they have some dental networks.  In network dentists have agreed to accept lower fees for those who have the plan in exchange for those companies to try and encourage them to go to their office.  Some insurance companies networks offer fees to dentists that are pretty close to what is termed UCR (usual, customary and reasonable), other insurances offer fees that are significantly lower.  The better your insurance pays, the more dentists who will have signed up for it.  Our office plan is to work with insurances who provide fee schedules that we can provide quality dentistry for.  We personally have chosen to not have different materials, different labs and different quality of work for different insurances.  It is unethical and something we don't want to be part of.  Most PPO plans will still allow you to see your preferred dentist and your benefits are the same, but the the dentists regular fees.  Some plans make it difficult to see an out of network dentist.  We always  are willing to do a benefits check for anyone so you know what we know about your plan.  

The last type is a HMO plan.  We do not participate in any of these plans and there are fewer dentists who do than the other types.  Most likely, you will be assigned a provider.  In our area, the dental chains are the primary providers for these plans (Bright Now!, Brentwood Smiles, Western Dental) although there are a few other offices that will be part of these plans.  Here a dentist will get paid a monthly fee for being your dentist and in return you get your dental care from that office.  Typically, HMO plans will cover very limited services.  The patient will have the choice to get these services and is typically pressured to upgrade to different types of treatment that is not covered by the insurance and has a higher fee.  Sometimes, the treatment that is covered is not something that any dentist would recommend, other times the fees for the covered service at HMOs are so low that the dentist will lose money on the deal.  Our recommendation is that is you have an HMO, try and get a different type of plan.  You deserve choice in who you see.  The most common HMO we see is DeltaCare USA which is administered by Delta Dental, but still assigns you a dentist.  There are probably some good offices that accept HMOs, but there are a lot of bad ones too that have a corporate bottom line.

In general, there are 3 entities that decide the oral health care for patients with insurance.  You are one.  Your dentist is another.  The third is the insurance company who is trying to not have you get any work done.  We will give a little more information on how your insurance benefits are given in another post.  

Interesting fact, while dental insurance was started to increase oral health care access, it hasn't done much more than complicate things.  In the 1960's it was estimated that 50% of people had visited a dentist in the previous year.  Currently, it is estimated that only 47% have visited a dentist in the previous year.  I don't think its working.  I'm guessing a lot of patients have been scared off from dentistry.  Maybe the grew up with an HMO plan.