I was watching some water polo on TV this afternoon. This isn’t a sport that is heavily televised outside of the Olympics, so it’s not something I’ve seen much of. Two things I noticed…
It is a SERIOUSLY rough sport. More fouls than hockey and more dirty tricks than professional wrestling!
Mouth guards. They all had them. At the time outs, they’d all swim to the side and take them out to discuss strategy. But as soon as they were subject to flying elbows and head butts, they were wearing them again.
The one thing I didn’t see while watching water polo? Avulsed teeth and bleeding lips. Although I did see a couple of black eyes.
If you play sports, you should have a mouth guard. If you’ve tried one and don’t use it because it’s not comfortable, come see me. We can make you a custom fit mouth guard that’s comfortable to wear and looks sweet. Team colors, American flag, whatever you like. They’re a little bit more than the boil and bite type you buy at the sports shop, but they cost a lot less than dental implants, crowns, bridges or (say it ain’t so) dentures.
If you have dental problems, it’s mostly your fault. And if you want to have less dental problems, it’s your responsibility. It’s not the fault of the dental insurance company. It’s not the government’s responsibility. It’s on you. What you eat and how well you take care of your teeth are decisions that you’re in charge of. And you’re in charge of these decisions for your kids. So, will you rise to the challenge?
“Wow, Doc. Kinda harsh.”
Maybe, but I recently saw a PBS Frontline special called “Dollars and Dentists.” Among other things, it accuses dentists of not doing enough to help poor kids with dental care. I’m hearing this more and more and it really irks me. Because 95% of all dental disease is completely preventable.
What I’m saying is that if you’ve never had a cavity, you can choose to keep that perfect record. If you have gingivitis, you can change that. If you’ve had dental troubles, you can stop the destruction and turn it around. And that goes for your children, too.
“Sure, doc. But, what’s the catch?”
There actually is a catch. If you get a lot of cavities or have gum disease it’s likely that your diet and lack of brushing/flossing have a lot to do with it. You see, tooth decay and gum disease are biofilm infections. Your teeth and anything else in your mouth (crowns, dentures, implants) are covered with a film of bacteria and bacterial products called a biofilm. How much of this biofilm (a.k.a: dental plaque) there is and how healthy it is has everything to do with how much decay and gum disease you experience.
“O.K. Doc, I get the “how much” part, but how can bacteria in my mouth be healthy?”
Once you become in charge of your own health, it’s time to step up. If you’ve been dealt the hand of tough mouth bugs, you’re responsible for changing them! Those who have already experienced dental troubles (cavities or gum disease) need to work even harder on their home care. The very fact that you’ve had dental problems lets us know that you have virulent (bad!) bugs. Brushing and flossing can reduce the number and location of these bugs on your teeth. But how do you change what kind of bugs you have?
Diet has a lot to do with the type of bugs that inhabit your mouth. If your mouth maintains a low pH (acid) for a long period of time, the kind of bugs that can tolerate that environment will become more numerous. What kinds of things keep a mouth acidy? Drinking pop. Specifically sipping pop slowly over a long period of time. Other habits like sucking on hard candies cause this, as well. Bathing teeth in a sugary, acidy environment will not only cause cavities but it creates an environment perfect for the nastier bugs. Changing your dietary habits can make a huge difference on the “environment” you create in your mouth. Reducing sweets, especially pop, as well as reducing how often a person snacks will go a long way to letting your natural defenses change the environment in your mouth. Chewing xylitol gum or mints can also change the kind of bugs you have in your mouth. Dentists can prescribe certain mouth rinses that can actually change the makeup of your biofilm over time as well.
Do it for him!
Your biofilm is your problem. Most people only see the dentist a few times per year. The choices you make on a day to day basis about diet and taking care of your teeth (or not) are the ones that really count. I can’t control what you or your kids eat. We can clean up your biofilm a couple times per year, but it will be back to the same the day after we clean your teeth. The choice is yours. So step up and take care of those teeth!
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I was doing an exam on a patient recently. The patient had quite a few silver fillings that were probably 20 years old or older. I had some concerns for some of the teeth. Not because of the age of the fillings. Fillings like these can often last 20 years or more. It was because of the fracture lines I could see.
This tooth exhibits several stained and diagonal cracks. The tooth had no pain.
I put took a photo with a digital camera and it popped up on the screen of the iPad after a couple of seconds.
“This tooth is showing signs of trouble. Can you see these little lines?”
I zoomed in the cracks.
“Those little lines are fractures in the tooth. Incomplete fractures. In other words, it’s a broken tooth waiting to happen.”
“I see, Doc. But it doesn’t hurt at all.”
“Interesting. Sometimes they’re painless. Often they’ll become sensitive on biting, but occasionally they’re free of any kind of symptom until they break.”
“Maybe I should just wait until it breaks. I mean, it doesn’t hurt.”
“We absolutely can do that. A lot of times, nothing bad happens by waiting. If it breaks, we’ll fix it. But sometimes the tooth breaks in an unpredictable way. Like underneath your gum, or even under the bone. When that happens fixing it can involve a crown and a root canal and possibly even gum surgery. Sometimes the tooth can’t be saved if it breaks in a bad way. That’s why I would recommend putting a crown on it before it breaks.”
“How do you know if it’s going to break badly?”
“I don’t. So really, I recommend you fix it the day before it breaks.”
The patient gave me an exasperated look.
An "internal" fracture that was underneath a filling. This tooth had pain on biting.
I know, I know. That is a very cheesy line. I use it all the time because it’s so true. A tooth with this kind of crack, particularly a stained or diagonal fracture is at great risk of breaking. The very best thing we can do for it is to cover it with a crown or onlay. As soon as possible!
In many cases there are internal fractures underneath fillings that have been in place for a long time. Sometimes we don’t see those until we remove the existing filling. These internal cracks are much more likely to be sensitive on biting. Sensitivity to biting is another symptom that shouldn’t be ignored and should be treated right away!
The moral of this story is…don’t wait! A tooth is less likely to have complications (like needing a root canal) if it’s treated as soon as problems are diagnosed. This dentist REALLY prefers no complications!
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It’s like this…drinking a lot of pop can cause cavities. The more pop you drink, and the slower you drink it, the greater your chances of getting cavities.
I’ve written about this before. A lot, actually. In fact, many of my patients get sick of me telling them about it. But hey…I’m a doctor. I’ll bet diabetics get tired of hearing their physician tell them that they need to lay off the M&M’s and donuts, too.
I recently examined a patient who admitted to being a serious on-the-job pop drinker. He told me with no prompting that he was done with pop. He didn’t like how it made his teeth look. So, of course, I took a picture.
"pop cavities" (click to enlarge)
He had a few things going on that are classic for pop drinkers:
front teeth: He had quite a few cavities, but they were limited mostly to his upper front teeth. If you think about it, that kind of makes sense. When you sip a highly acidic and sugary beverage what does it hit first? Your upper front teeth. So that’s where the acid and sugar starts to work.
“white spot” lesions: This is the chalky, white spotting that you can see on tooth enamel that has been partially dissolved by acid. The good news about white spot lesions is that with some intensive fluoride treatment they can be reversed. However, continued acid and sugar will cause a white spot lesion to turn into a…
“pop cavities:” That’s just what I call them. This is the yellowish-brownish hole you can see once the acid has really broken through the enamel of your tooth. The second layer is darker colored and much more susceptible to the acid. Once you lose your enamel, that tooth is a much greater risk to form a pop cavity.
So what can you do if you like your pop so much that you don’t want to stop? I have a couple suggestions:
So, are you a pop drinker? You ought to check out your front teeth in a mirror. Or, better yet, come in the office and let us take some photos. We can take a look at them together on the iPad and see if you’ve got any “pop cavities.”
Did you find this post refreshing? Fizzy? Annoying? I’d love to hear about it! You can share any Mead Family Dental post with a “Like” on Facebook, a “+1″ on Google+ or you can even “Tweet” it with Twitter! All you need to do is hover over the heart shaped button next to the title of the post. Or you can leave a comment by clicking on the balloon shaped icon next to the title.
Yesterday ABC played a story in their “Hidden America” series entitled “Do Dentists Turn Children Away.” It’s an emotional piece, for sure. It features many adorable low income kids in various states of dental distress and it levels some pretty serious charges at government and the dental community. Chris Cuomo, the story’s reporter, ended the story with, “…we went after them 5 years ago, it didn’t get done. This time we will not rest. This is unacceptable.” Diane Sawyer replied “And what about the good dentistsout there that want to help the 60% [of children on Medicaid without a dentist] who are living their lives right now and can’t wait…” Chris Cuomo went on to mention that some dentists are “doing the right thing…” The take home message I get from this report is that “dentists don’t care about poor kids.”
This report comes on the heels of ABC’s coverage of “dental x-rays causing brain tumors.” It seems that dentists are getting all kinds of help from ABC news to tarnish our images this month! Like we needed it! So why won’t dentists take care of these needy kids? Is it that they don’t care? Or maybe they’re just unwilling to make less money while helping poor people. Either way, dentists are clearly bad guys.
I can only speak for myself. I’ve discussed this with other dentists often and most tend to agree with my perspective, though. I do take limited amounts of Michigan’s version of Medicaid dental coverage for kids/adolescents/young adults. Why don’t I take more? Here’s a few of those reasons:
limited services: This is probably the main reason that I’m hesitant to get more involved with these programs. I have a toolbox that I bring with me when I treat patients. (Not literally…I actually have an office!) I have a lot of different treatments to offer for different dental problems. Some of these tools work better in some situations, some work better for others. In extensive problems, some of these just aren’t workable. One of the things that frustrates me is that Medicaid will pay for a root canal procedure to save a tooth, but they will not allow you to restore the tooth appropriately after the root canal treatment! A lot of teeth that end up requiring a root canal have lost a lot of tooth structure. A filling is inadequate for these teeth, but that’s what is covered. If I go ahead and do what I feel as appropriate, the program will not cover it and it becomes the patient’s responsibility. Most patients aren’t willing or able to pay for the appropriate treamtent. So, my toolbox gets much smaller for patients using these programs.
limited payment: The fees that the Medicaid programs pay are low. That’s what everyone knows. The news programs always say this, but they never dig any deeper than that. To be specific, Healthy Kids dental in Michigan reimburses my office at about 50% of my regular fee. People hear this and think that dental offices make 50% less when they see kids on the Healthy Kids program. That’s not accurate. Most dental offices are small businesses run to make a profit. A dental office needs to collect a certain amount of money just to pay rent, utilities, equipment costs, employees…the basics. This is called overhead, and every business has it. You need to average a certain number of dollars for each unit of time in order to keep the doors open. If you don’t average this amount, the office doesn’t make a profit. Some offices can change their overhead structure by working more quickly, seeing more patients, using less expensive materials or paying their employees less to make up this difference. I won’t do that. I don’t want to have to change the way I treat patients to be able to participate with the program. My patients expect amazing service and a certain atmosphere and I’m not willing to sacrifice that. You may think that makes me a snob, but I think my patients appreciate it. So, when I see Healthy Kids patients, I’m working for free. The good news is, overhead is figured on an average, so I’m willing to take a loss on some patients. But as I mentioned before, I limit the number of patients I will see on the program.
ethical traps: Medicaid programs give each provider dentist a particular menu of procedures and their associated codes that are covered benefits. It could be tempting for a dentist to “overuse” a code that they wouldn’t normally charge separately for. I’m not saying that it’s wrong to do so and I’m not saying that it is common. All I’m saying is the that the temptation to “overcode” can be there.
All kids deserve healthy teeth!
dental prevention: Most dental diseases, especially in children are 100% preventable. These programs are at their absolute best when they are used for prevention: specifically early childhood examination and education of good dietary and brushing habits. Unfortunately, most people end up in need of these services after a child has problems, often really bad problems. The horse is already out of the barn at that point. These programs become much less helpful for those patients, and they will often need extensive care that can only be handled by pediatric dentists.
This is where I’m coming from. I’m not sure it would be a satisfying answer for Diane Sawyer. It’s a lot better TV when you can point the finger of blame at a particular group, especially when a lot of folks are pretty anxious about that group in the first place. The news media plays a story that riles people up, and then they forget about it. In the mean time, people look at dentists as greedy and uncaring. If you feel like dentists aren’t doing good things for poor kids, you need to ask yourself: in the same position, would you be willing to work for free? How much work would you be willing to do for free?
The Michigan Dental Association will be sponsoring it’s first Mission of Mercy in June of 2013. These amazing events allow Michigan dentists to see around 2000 patients in a weekend for no charge. Next year’s Mission of Mercy will be held on campus at Saginaw Valley State University. I’m planning on being a part of the 2013 MOM. I think this kind of event is an effective way to help people who might otherwise not be able to get dental care. So Diane Sawyer might have it wrong about dentists!
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“Al, I’ve seen the phrase ‘levels of radiation that are so small as to be insignificant’ used a fair bit in the last few years. Particularly in relation to the Japanese disaster and the observation of levels of radiation around the world due to it…I think it would be instructive to have hard numbers to compare to background and other common sources that are considered safe.”
I agree. I’ve been explaining how safe x-rays are to patients for so long, I’ve kind of forgotten about the actual amounts of radiation that we expose them to. So let’s talk a little bit about radiation.
Electromagnetic radiation like visible light and x-rays travels in waves. And I have a cool graphic of it.
Electromagnetic radiation, or EMR, is any form of energy that travels in a wave. Visible light, radio waves, microwaves and x-rays are all forms of EMR that are common to us. The different types of EMR are characterized by their wavelength and frequency. Longer wavelength radiation like radio waves and have a lower frequency and are considered “low energy.” The shorter the wavelength the higher the frequency of the energy and generally these are “higher energy.” Very high energy like x-rays and gamma rays that can cause an electron to break away from an atom are considered ionizing radiation. These are the kinds of radiation that can cause health problems. Too much ionizing radiation can cause damage to the DNA in a person’s cells, which can lead to tumor formation and even cancer. The high energy state of x-rays is also what makes them so useful for seeing structures inside the body. Visible light is stopped by the skin and soft tissues around your bones and teeth, but x-rays can penetrate through them to show us things that we cannot see with visible light alone.
Harm from radiation sources is “dose dependent,” which means that more is worse. So in order to maintain safe levels of radiation in the dental office we need to know what kind of dose that we’re giving. The dose of radiation is measured in millirems or mrem. You can actually calculate common radiation doses using this chart from the American Nuclear Society.
So what is a “safe” level of radiation dosage? According to the American Nuclear Society the average level of radiation per person in the United States is 620 mrem/year. The safe allowable dose for people that are exposed to radiation in their work (nuclear plant workers, radiology technicians) is 5000 mrem/year.
Here are some examples of radiation dosages for different common exposures:
1 bitewing or PA dental x-ray: 0.5 mrem
2 hours in a jet plane: 1 mrem
1 panoramic dental x-ray: ~3 mrem
living in a stone, adobe or concrete house (instead of wood frame): 7 mrem/year
a full mouth set of dental x-rays: 9 mrem
chest x-ray: 10 mrem
1 pack of cigarettes each day: 36 mrem/year
chest CT scan: 700 mrem
whole body CT scan: 1000 mrem
These numbers reflect conventional film x-rays. Many dentists use digital x-ray technology which needs significantly less radiation to make x-ray images. In some cases the amount of radiation needed is 80% less than conventional film radiography, which would yield even lower radiation doses.
How much is too much?
Even though dental x-rays have an incredibly low dose of radiation, it makes sense to limit the amount of radiation as much as possible. Patients with a proven track record of low decay rate are an example of a type of patient that may not need diagnostic x-rays each year. Other diagnostic methods like high magnification with intense lighting, evaluating saliva flow and dietary evaluation can help determine a patient’s risk for new decay. For patients who have experienced cavities recently or new patients that don’t have a track record with their dentist, taking dental x-rays on a regular basis is necessary diagnostic tool.
So what’s a patient to do? How do you know if an x-ray is necessary? You need to ask your dentist. And if you don’t feel like your dentist is hearing you, perhaps you need to find another. Having a relationship with a dentist whose opinion you trust is a great way to know that you’ve found a good balance between too many x-rays and not enough information to prevent dental problems.
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I see it all the time. A look of concern on a mom’s face while their child is having their teeth cleaned. “Are there cavities?” they wonder. “Will they need braces?” Wouldn’t it be nice if you could relax in our comfortable waiting room knowing that your kid is going to have a brilliant dental check up? Here’s some things you can do to give your kids a really good shot at dental health!
Be a great example: Your kids see and hear everything that you do. And they somehow always repeat what you’ve said at incredibly bad times (think “daddy doesn’t like Grandma’s cooking” at Thanksgiving dinner). So they see how you take care of your teeth, too. They notice if you brush and floss often, or not. They’ll see you chew sugarless gum after meals and will probably want some, too!
Get your teeth fixed: tooth decay and gum disease are a bacterial infections. They are transmitted in a similar fashion to a cold. The bugs that cause tooth decay are almost always transmitted from mother to child, although anyone who is a prominent care provider (dads, grandparents) can also transmit them. What I’m saying is that your kids will have your bugs. What determines what kind of bugs you have? People who have lots of cavities, particularly lots of untreated cavities will have nastier bugs. So, if you’ve got a history of lots of cavities or you have work that you need to have done, you probably have nastier cavity bugs. And you’ll probably transmit them to your kids. The moral of the story…have your teeth fixed and your kids will have healthier teeth.
Bring ‘em in early, and often: The American Academy of Pediatric Dentistry (AAPD) recommends “first visit by first birthday.” Practically speaking, you should bring them in once they have their first tooth. And they should be checked every year after that until they start having their teeth cleaned, which is usually around the age of 4. Having a dentist look at your child’s teeth often can help find problems while they’re small. Since baby teeth are actually more susceptible to cavities than adult teeth, this is pretty important.
You brush their teeth, then let them brush their teeth: It’s great to raise independent children. It’s great that they want to take care of themselves. But you need to brush their teeth. An adult should brush first, then the kiddo brushes second. Parents, you’ll need to brush with a firm hold on your little cherub’s head. And you need to retract (pull apart) their lips with the hand that you’re holding their head with so that you can see the surfaces of their teeth. As one pediatric dentist once told me, “if you can’t see what you’re brushing, you’re not brushing it well.” Once you’ve scrubbed all the surfaces, then let the child have a chance to do the same thing. How long until they’re old enough to brush on their own? Well, my oldest is 4 years old and I’m thinking it’s going to be 6 more years of me using the “loving headlock” on him.
No bottles in bed!
Don’t put a baby down with a bottle: Don’t get in the habit of putting your baby down with a bottle. Once they get used to it, it’s much more difficult to break the habit, so don’t do it! Even if you’re giving them formula or breast milk, there are still sugars in them that can be turned into acid by cavity bugs. Pediatric dentists often times call the massive tooth decay found in very young children “baby bottle tooth decay” for a reason. If you have to put a baby to bed with a bottle, use only water!
Reduce the juice: When you think of fruit juice you think of “wholesome” and “healthy.” When I think of fruit juice I think “tons of sugar” and “high acid content.” Kids should have limited fruit juice intake. It’s really tough on teeth and almost always has a lot of added sugar. I know it goes against how fruit juice is marketed, but it’s true. Eating fruit = great! Drinking fruit juice = really bad for teeth. If you want to give your kids juice, do it at meal times…not snack time!
If you do these things the risk factors for cavities and other dental problems can be reduced significantly! So when you’re waiting for your baby to have their cleaning finished you can sit back, relax and know you’ve done your job. Ahhhh! Doesn’t that feel better?
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It’s basketball season. So we’re seeing a lot of fans. MSU fans, U of M fans, Pistons fans and a whole lot of different high school basketball team fans. Those fans LOVE rebounds! Those aren’t the rebounds that I’m talking about.
Quite a few of our patients 50 and older are taking some kind of anticoagulant medication. Aspirin, Coumadin, Plavix or even the newest ones like Exanta are used to prevent the buildup of plaques in the arteries of the heart. And they work. They cause the blood to be less “sticky,” which can help reduce the risk of heart attack, stroke and embolism in those with artery blockage. The side effects are that they can cause bruising and extended bleeding from wounds. Some dental treatments, particularly surgeries like tooth removal, can cause mild to moderate bleeding. Since bleeding is the first step in wound healing, this is O.K.
In the past, those taking anticoagulant medications were sometimes told to stop taking them 2-3 days prior to a tooth extraction. It was a gray area. Some docs said 2 weeks, some docs said a couple days and some docs said “don’t worry about it.” A lot of patients have been taking these medications for awhile and what they remember is that they stopped taking them for an extraction.
More recent research has described the “Plavix rebound.” It happens when someone discontinues anticoagulant therapy suddenly. Like 2 days before an extraction. This rebound effect puts the patient at significantly higher risk of stroke, heart attack and embolism for the NEXT 90 DAYS! Although most of the current research is with Plavix, the same effect has been known for quite some time with older anticoagulants.
So let’s say you’re on an anticoagulant and you need a tooth removed. My experience has been that in most cases we can remove the tooth and control any bleeding in the office without taking you off your medication. We have a lot of techniques including more minimally invasive surgical techniques as well as wound closure techniques that make postoperative bleeding a non-issue. If you or your doctor have concerns about wound healing I’m happy to discuss it with your doctor. But my guess is that now the risk of “rebound” is much greater than the risk of postop bleeding.
So here’s the deal: DON’T STOP TAKING YOUR ANTICOAGULANT MEDICATION WITHOUT TALKING TO YOUR DENTIST AND YOUR DOCTOR. Even if you stopped it in the past.
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“O.K. Doc. I hear you. Tooth problems don’t always hurt. So, if it doesn’t hurt, how do I know I have a problem?”
That’s a good question. When a patient isn’t having any problems we would say that don’t have any symptoms. But they may have signs of trouble that they aren’t aware of.
Symptom: “a departure from normal function or feeling which is noticed by a patient, indicating the presence of disease or abnormality. A symptom is subjective, observed by the patient, and not measured.”
Sign: “A dental sign is an objective indication of some medical fact or characteristic that may be detected by a dentist during a dental examination…”
So, how does a patient know if there are any signs of problems? They need to go to the dentist. Regularly. Ideally they go to a dentist that they trust and that they’ve developed a relationship with over a period of time. A dentist uses symptoms (from the patient) as well as signs (collected by examination) to find problems. Ideally, problems are found when they’re very small and need minimal treatment. The best way to make sure problems are found early is by scheduling regular checkups with your dentist. Every six months is the minimum that I would recommend.
Some patients should be seen more often than every 6 months. Who are these patients?
Patients who have “unstable” periodontal disease: If there’s advanced bone loss and we’re not sure that we’ve arrested the disease process we’ll want you to come in more often. Every three months is preferred.
Patients with a high rate of decay: If you’ve had multiple cavities in the last year I’m going to want to check you pretty often. I’m also going to want to help monitor your diet (less pop, more xylitol gum) and probably will recommend fluoride varnish treatments every three months, or even more often.
Patients on a lot of medications: multiple medications often means a dry mouth. Dry mouth is a huge risk for tooth decay.
Patients with a history of head and neck radiation: radiation treatment for cancer can cause your salivary glands to produce much less saliva. This is a huge risk factor for tooth decay and these patients should be seen every 3 months or more often for preventive care.
“Aren’t you just trying to scare us into coming in more often?”
We go to any length to get you to make an appointment at Mead Family Dental
No. But if that’s what it takes, I’ll put on my Ghostface mask.
The bottom line is this…just because it doesn’t hurt doesn’t mean that everything is fine. You should be seeing your dentist at least every 6 months. Plus, you should make an appointment immediately if you have any of the following:
a broken tooth: Whether it hurts or not, this needs to be seen and treated. A broken tooth that doesn’t hurt is a time bomb waiting to ruin your weekend, your vacation or a good night’s sleep. Broken teeth seem to know about Murphy’s Law and usually become a problem when your dentist isn’t in the office.
a food catcher: Do you have a spot between your teeth where food always gets stuck? These “food traps” can and should be treated. This is a great place for a cavity to start.
lost crown or filling: As much as you’d like to believe (and so would I) that all dental work lasts forever…it doesn’t. A crown or filling that comes out is a none-to-suble hint that there’s a problem. This needs to be seen!
trauma: Did little Billy bump his tooth on the coffee table? Did Dad take a softball to the chin? Teeth that have been bumped can sometimes act up. Even if everything feels O.K., you should have your dentist take a look.
Make sure to let your dentist know if you do have symptoms. A patient’s description of the problem is the first step in determining a diagnosis. If your dentist isn’t listening to your concerns and symptoms, speak up or find another dentist!
Did find this post helpful? Annoying? I’d love to hear about it! You can share any Mead Family Dental post with a “Like” on Facebook, a “+1″ on Google+ or you can even “Tweet” it with Twitter! All you need to do is hover over the heart shaped button next to the title of the post. Or you can leave a comment by clicking on the balloon shaped icon next to the title.