I recommend a crown or an onlay to lots of my patients. It’s one of the most common procedures we do and we do it very well if I say so myself. A crown is created by a lab and cemented over top of a patient’s existing tooth structure to restore form and function and to reinforce that patient’s tooth. They’re very predictable and work really well.
“How much does this wonderful service cost?” you might ask.
The answer is going to vary by geography but it’s typical for a crown to cost around $1000. A little less in some place, a lot more in others.
“A thousand bucks? You’ve got to be kidding me! That’s a lot of money for one tooth! Who do you think I am, Bill Gates?”
I hear you. $1000 is a lot of money. Who wouldn’t want to spend it on something else. Something fun like a phone, some shoes, a trip or whatever. But let’s take a look at that $1000.
Our office charges slightly less than that $1000, but the math is easier with $1000.
Most dental benefits companies will replace a crown after it’s been in the mouth 5 years. That is not typical, though. My experience tells me that crowns typically last 15 years or more if the patient has good oral hygiene, good saliva flow and has risk factors like dry mouth and high decay rate under control. Lets take 15 years as a reasonable lifespan for a crown.
Now be honest…what other things do you own that have lasted for 15 years? Is your car 15 years old? How about your phone? Your shoes? Bottom line, there’s almost nothing that you spend money on (sometimes a LOT of money on) that lasts as long as dentistry does in a healthy mouth.
A $1000 crown costs you $1000 on the day that you pay for it (or less if you are using a dental benefit…your mileage may vary).
If that crown lasts for 15 years, you’ve amortized your investment in that crown to $66.66 per year. So for $67 you’ve got a beautiful and functional tooth that you probably don’t have to give another thought.
Is $67/year a little too abstract for you? How about this. You’re talking about $5.55/month over 15 years for that crown. One less latte from Starbucks will give you pain-free beauty and function.
OK…let’s get stupid here. 18 cents per day. That crown is three nickels and three pennies per day for 15 years of chewing, smiling and not thinking about it. I’d say it’s worth it in spades.
It actually gets better, though. I’ve seen crowns last longer than 15 years. If you’re really good about taking care of your teeth and watching your diet there is no reason a crown cannot last longer. I’m not going to pretend that ever crown is problem free. To be honest, if we’re trying to restore a particularly broken down tooth, it’s tougher to get that predictability and longevity. Furthermore, some teeth require root canal treatment (again…the more beat up the tooth, the more likely this is). So I don’t want to oversimplify.
The point is to look beyond the price tag that you see in the office and think of the cost over the life of the crown. These restorations feel expensive on the front end, but if you look at the long run they’re a pretty great bet!
Did this make you feel thrifty? Did it make you want to invest in a new crown? 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.
Last week I found myself in a spot that I don’t like to be in. A couple of times. I found myself preparing a crown on a tooth that was in much worse shape than I would like. One case was a new patient that I had just started treating. The other patient was one that had waited on treating the tooth until it broke. We had diagnosed an “incomplete fracture” on the tooth some months (years?) before and recommended a crown, but for whatever reason the patient had decided to wait. As I’ve discussed in the past, most dental problems don’t hurt until they’re a big problem.
Crowns or onlays are “indirect restorations.” Which means they are made indirectly from the tooth, by a lab. Direct restorations are made right on the tooth…most people would call these “fillings.” By the time a tooth is in need of an indirect restoration there has probably been a lot of tooth structure lost. Most of these teeth have been worked on before, often having had direct restorations placed. How do we know when a tooth is ready for an indirect restoration? There are a few signs I look for:
cracks: the way teeth are designed is interesting. The outer enamel layer is very brittle and it’s stuck to a deeper dentin layer that is slightly softer which surrounds the pulp (nerve, blood vessel and connective tissue) which is soft and gooey. This is some amazing structural design, but as you age and your teeth are filled, heated, cooled and used for biting…they can develop cracks. Sometimes the cracks are superficial, sometimes they are deep. The good news is that at Mead Family Dental we’re pretty good at finding them. The microscopes that we use throughout the whole office are great at helping us see fractures in teeth…often before they become a big problem.
wear spots: as you age, you wear your teeth. Some people wear their teeth significantly more than others. Just like tires, once you’ve worn your teeth down, they don’t fix themselves!
existing restorations that are failing: What do you mean my filling broke? It’s only been in there for 15 years! I wish every restoration I placed would last forever, but that’s not how it works. Ask yourself this question: has it ever seemed like you justbought a new set of tires and then you see that you actually got them 50,000 miles ago? Yeah…restorations in teeth seem kind of like that, too.
decay under an existing restoration: Your mouth is full of bacteria and your teeth are covered in biofilm…even if you’re a terrific brusher! Those bacteria are tiny and all it takes is a small leak in a filling or crown for them to sneak underneath and start multiplying. It happens to the best of fillings and crowns. Luckily, we can usually fix that decay so long as we are able to catch it early.
Your adult teeth have been functioning in your mouth since you were about 6 years old. They’ve been through a lot. Accidentally biting an olive pit, millions of hot—>cold and cold—>hot thermocyles (have you ever eaten ice cream while drinking coffee?) and hundreds of thousands of acid attacks. Frankly, teeth hold up amazingly well considering what we put them through. There’s no shame in having to reinforce what you were born with. In fact, I would suggest that it’s best to do this as soon as any of those signs start showing up.
Here’s the thing…the longer we let the problem go, the more difficult it is to fix. Ask any dentist and they’ll tell you. It’s much easier to save a tooth before it’s broken than after. Small cavities are much easier to deal with than big cavities. I’d much rather do an onlay on a tooth now than wait until it needs a root canal. I realize this sounds incredibly self serving for the guy who gets paid to fix your teeth to tell you that you should jump on things earlier than later. But remember, I’m a giant wuss when it comes to delivering bad news. I’d much rather place a really well fitting crown on a tooth with a healthy nerve and gums and solid bone to support it. The longer we wait on cracks, decay and failing restorations the worse the outcome is likely to be. No dentist wants to “make the save.” Teeth that have these problems are more difficult to clean up, more difficult to impression and more difficult for the lab to make an ideal restoration.
So, the moral of the story is…don’t wait! Often times I can make the save. But I’d much rather not have to!
Did this make you feel safe? Did it make you want to only eat soft and lukewarm things? 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.
Contrary to what you hear from a LOT of dental marketing, heart disease isn’t caused by gum disease. It’s technically correct that gum disease and heart disease are correlated or “linked,” but there is currently no evidence that gum disease causes heart disease. Or stroke. Or other health problems.
Here’s the thing…a lot of these diseases have similar risk factors. For instance, if you are a smoker you are at greater risk for heart attack and stroke as well as gum disease (as well as countless other health problems). So the correlation between these maladies may have more to do with similar risk factors than the actual expression of the disease.
I’m not saying that treating gum disease is unimportant. It absolutely is important and worthwhile! Treating gum disease early and thoroughly (which includes teaching patients how to maintain their gums and teeth at home) could help patients avoid pain, infection, tooth loss and expensive dental work in the future. A few years ago I compared gum disease to one of my favorite comic book characters:
“So imagine this calculus on the surface of the roots of your tooth like a bunch of tiny slivers. Your innate immune system recognizes it as a bad guy, but cannot remove it. This makes the innate immune system mad. Kind of like when Bruce Banner gets mad. And the madder your innate immune system gets, the stronger the reaction it creates to try and remove this invader. It starts dumping the toxic chemicals it uses to kill bad bacteria and other bugs into the tissues supporting your teeth! These chemicals, along with toxins from the biofilm itself, start to break down the tissues that support your teeth. It’s kind of like you have an angry Hulk smashing around in your gum tissues, but he’s not able to get rid of the bad guys. And this makes him really angry! So instead, he starts attacking YOU!”
Essentially, gum disease is a combination of bacterial build up in your mouth and your immune system creating inflammation that breaks down the tissues supporting your teeth. Localized inflammation around the structures of the teeth causes the problem. Can this localized inflammation cause inflammation in the rest of your body?
The best answer at this point is, “maybe.” Ongoing research could indicate a more direct causative effect in the future. But for now, it’s not there. Even the American Heart Association agrees. The best way to prevent heart disease still continue to be:
quit smoking (and if you don’t smoke, don’t start!)
maintain a healthy weight
control your blood pressure
For the moment, treating gum disease isn’t on their list.
There are some dental professionals that try and use this “connection” between gum disease and “whole body health” as a scare tactic in order to promote treatment. Some even want to teach this technique to other dentists to help “fatten the bottom line” for dentists. Which is just perfect, right? As if dentists need something else to wreck our reputation as a profession.
Again, I want to stress to patients that treating gum disease is worthwhile in its own right. We’re interested in your overall health as well…that’s why we screen blood pressure and do a thorough medical history. But treating your dental needs is worthwhile without the baggage of unscientific claims and scare tactics.
Did this make you feel anxious? Do you feel holistic? 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.
I remember when Bubble Yum bubble gum came out. Wikipedia says it was in 1975 and that feels about right. I remember commercials with a puppet that was trying to steal a kid’s Bubble Yum.
I also remember the gum itself. It was the first “soft chewing” gum in memory. Before Bubble Yum, it was either sticks like Trident or rock hard little nubs like Bazooka. Bubble Yum made chewing gum more fun. It also had a ton of sugar in it. So much you could feel the little grains of sugar as you bit into it. It was glorious, but it promoted tooth decay. The rare times we were allowed candy (yep, my dad was a dentist) I usually chose grape Bubble Yum. It was one of the flavors that defined my childhood!
Fast forward about 40 years. My diet includes things that cause tooth decay. The saliva in my mouth is a natural defense mechanism of my teeth. Healthy levels of saliva can keep the acid that causes cavities in check.
I’m not alone. I see lots of patients with decay problems. They have sugary diets, too. And many of them have a dry mouth as well. Any time a person takes more than one medication (which is very common) there is a high likelihood that their medications has induced dry mouth.
Dentistry has done a terrible job with dry mouth. We see it all the time. We can explain to our patients why they might experience it. But we don’t have much in the way of treatment for it. We can offer dry mouth rinses and toothpastes, but my patients that have tried them overwhelmingly feel like they don’t work very well. I don’t recommend that patients change their medications to treat blood pressure, depression or anything else. So mostly people just live with dry mouth.
I’ve found a solution that takes me back to my childhood. No, it’s not grape Bubble Yum. But it tastes and chews almost exactly the same. I’m here to tell you that Arctic Grape Ice Cubes gum is my suggestion for dry mouth. It’s as close to a perfect solution for dry mouth as I could invent.
It’s delicious. It tastes identical to the Bubble Yum I remember from the 70’s. Right down to the little grains of sugar. Except that it’s actually sugarless.
It really increases your saliva. Pop a couple of pieces in to chew and your mouth becomes flooded. It’s nothing short of amazing!
It’s sugarless. So even though it tastes really good, it won’t promote tooth decay. In fact, it’s flavored with xylitol which is known to inhibit acid production by the bacteria in your mouth in high doses. The amount of xylitol in this gum isn’t clinically proven to do that, but it’s still better than using sugar to sweeten the gum.
The best treatment I’ve found for dry mouth takes me back to my childhood. How cool is that?
Did this make you feel juicy? 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.
Every dentist has experienced it before. Patients refuse x-rays because they don’t want to be exposed to too much radiation. What is “too much radiation?” That’s a great question.
Medical professionals have been taught since the 1940’s that medical and dental imaging carries a tiny chance of increasing a person’s cancer risk, no matter how low the dose. The model that we were taught is called the “linear no-threshold model” (LNT) and it basically claims that any dose of radiation, no matter how small, carries an increased risk of causing cancer. As dentists, we are supposed to weigh this tiny (but not zero) increase in risk against the benefits of whatever x-ray image we wanted to see.
New research published in the American Journal of Clinical Oncology has re-evaluated the original research that we based the LNT model on and has found it to be unconvincing. The original research was performed by exposing fruit flies to various doses of radiation. The damage at each level was measured and the research made the assumption that there is no completely risk-free level of radiation.
In the LNT model, the well-established cancer-causing effects of high doses of radiation are extended downward in a straight line to very low doses. The LNT model assumes there is no safe dose of radiation, no matter how small. However, the human body has evolved the ability to repair damage from low-dose radiation that naturally occurs in the environment.
Basically, the radiation doses that were studied in the 40’s were much to high to extrapolate into low dose medical uses of radiation. We’ve based our concerns about x-ray radiation on doses that are much higher than those experienced by patients. The recent paper was specifically about CT scans, which actually have a much higher exposure to radiation than dental x-rays.
As a profession, dentistry has gone out of its way to expose patients to as little x-ray radiation as possible. But many patient still balk. The effectiveness of x-rays for dental diagnosis cannot be underestimated. But not only are they effective, current research suggests that they are completely safe.
Did this make you feel radiant? Do you feel relieved? 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.
I recently had a patient cancel her appointment at the last minute. This happens sometimes. It’s frustrating for a dentist or hygienist when we’ve set time aside for a patient and they don’t come. Usually there’s a good reason. In this case, no reason was given.
As I sometimes do…I took it personally. Why did this person choose not to have the treatment done that we discussed? What could I have done better?
This particular patient has been coming to our office for years. She is someone you might describe as “skeptical” of dental treatment. I suspect she had some bad dental experiences before I even came into the picture. She’s at least mildly phobic of dental treatment, too. However, I think she’s probably one of those people that believe that when I come in the room that I’m simply looking for work to do, probably to line my pockets.
It’s a difficult spot for a dentist. Often times we’re both the internist that diagnoses the problem and the surgeon that fixes it. Patient see this as a conflict of interest. The guy who is telling me that I have cavities is also the guy who benefits from them being fixed. I completely understand this. I take my role as a doctor very seriously and I put my patient’s needs first. But can you blame a patient for being skeptical of a doctor’s motivations?
When I examine a patient I’m looking to see what level of dental health the patient has. And when I see a problem, I’m obliged to tell them about it. I have found what I believe is the most effective way to do this. I do all of my recall exams with a dental operating microscope. This microscope magnifies what I can see and has a very bright light that allows me to see parts of the mouth that don’t get lit up very often. I’ve attached an HD camera to the microscope with a monitor mounted over the patient to allow them to see exactly what I’m seeing…as I see it. I feel like this is a great solution to the problem of showing the patient what I see instead of me just describing it. I like it more than still photos because I can show it to them “live” as I’m describing it.
Back to my patient that chose not to come in today. I definitely examined her with the microscope and I definitely showed her what I was seeing. I recommended to some treatment because I saw some problems. I try and do this dispassionately. I try not to “sell” a patient on treatment by showing them what I’m seeing. I try to help the patient choose dental health by showing them what I’m seeing and describing what we can do to correct dental problems.
I have a suspicion that this patient still thinks what I’m describing isn’t a real problem. Like many dental problems, what I’m describing probably doesn’t hurt. Most cavities don’t hurt. Gum disease almost never hurts. Even broken teeth often aren’t painful. If you use pain as the threshold for dental treatment, you’re probably going to end up choosing the most expensive way to fix the problem or worse, sometimes the problem can’t be fixed leading to the loss of a tooth. A small cavity left untreated almost always becomes a bigger cavity, so what may have been easy to fix with a filling could end up needing a crown or even a root canal. This sounds like a scare tactic used by a dentist. Ask any dentist and they’ll explain that they see it. All. The. Time.
So I’m going to suggest that you listen to your dentist’s recommendation. The choice to treat is always yours. But almost always, the sooner you treat a problem, the less expensive and potentially painful the fix is.
Did this make you feel skeptical? Are you feeling put under the microscope? 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.
A couple of days ago a friend was complaining to me that he had gotten something stuck between his teeth. He’d had lunch at a barbecue joint and wouldn’t you know it he had some brisket jammed between his molars. He was looking for a toothpick or a straw to get it out because it was kind of uncomfortable.
If you’ve ever suffered the same fate you’ll know what I’m talking about. It isn’t necessarily painful, but it’s a kind of persistent pressure that doesn’t really let up until you get whatever is jammed in there out. There are a lot of nerve endings in the gums and the tissues that support the teeth that tell you brain, “hey, something funny is going on here.”
So I whipped out the floss that I carry in my pocket and rescued him. It took him about to seconds to snap the offending piece of brisket out and he was good to go.
“I’m lucky you’re a dentist,” he said as if it’s a given that dentists don’t go anywhere without floss, a toothbrush and maybe a spare dental mirror for good measure. The reality is my dirty little secret.
In a perfect world, the contacts between your teeth are tight enough that normal chewing doesn’t wedge food between them. Too tight makes it so flossing to remove plaque and food debris is difficult or impossible, but too loose means food can become impacted. Food impaction is an inconvenience to be sure, but it can become a problem. A spot where food impacts is more prone to decay simply due to the fact that you cannot remove the debris. The bugs (and by bugs, I mean bacteria) that sit there will metabolize the sugars in the impacted food into acid. When the pH of that part of the mouth reaches a critical level (5.5 to be exact) then the enamel of your teeth will start to dissolve. The longer impacted gunk sits there, the greater the chances that the pH can drop into dangerous levels and cause cavities.
Impacted food can also cause gum problems. I’ve spoken with periodontists (gum specialists) that have removed popcorn kernels from gum abscesses. People with gum disease are more prone to food impaction because their teeth are slightly more mobile than those without bone loss around their teeth. The bottom line is that places where food gets impacted are at greater risk for cavities and gum disease.
Why do we have spots where food gets stuck? Well, some people have naturally loose contacts between their teeth. As I mentioned, people with gum disease are definitely more likely to get stuff stuck in their teeth. If you have a broken or badly decayed tooth they will often be a spot that holds food debris. Finally, dental restorations like fillings or crowns can have inadequate contacts and be a risk factor on their own.
How do we fix it? Well, if you have naturally loose contacts between your teeth I’m not going to “fix” them if they don’t have disease. Those folks need to be extra careful in their brushing and flossing habits. Contacts that are particularly annoying to a patient can usually be “closed” in a minimally invasive fashion if the patient chooses. But if the loose contact in question is caused by decay or worse, the tooth is broken, we better fix it pretty fast!
Dentists probably floss more often than regular folks, but there is no law that requires dentists to carry floss. I carry floss because I have two very loose contacts. Both of them are caused by restorations that have opened up over time. I need to get them fixed and I’ve been procrastinating. That’s my dirty little secret. It may surprise you that dentists are like other human beings…some of us put off treatment that’s necessary, too. But that’s no excuse! Let’s unite in our commitment to close open contacts! No more food impaction!
Did this make you feel ashamed? Do you feel differently about dentists? 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.
Are you one of those people that has never had a cavity? Or maybe you’re one of those poor folks that seems to have new cavities every time you get your teeth cleaned. Why do different people experience such different levels of tooth decay?
In today’s podcast Dr. Mead talks about risk factors for tooth decay and the things you can change as well as the things you can’t change about your own individual risk levels.
Did you like this podcast? I’d love to hear about it! You can share any Mead Family Dental podcast or 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. Better yet, subscribe to the podcast on your iPhone so you can catch Dr. Mead’s weekly podcast automatically!
Two words that have become familiar to anyone who watches TV. Osteoporosis, or decreasing bone density, is a common problem as we age. Although it is painless, it can increase risk of bone fracture which can precipitate all kinds of debilitating problems. So now, every time you turn on the television you see ads for medications that help prevent or slow bone loss due to osteoporosis.
Dentists see a very different kind of bone loss. Have you ever noticed that our stereotyped vision of an old person almost always includes that “caved in face” look around their mouth? That’s bone loss, too. But it’s a very specific kind of bone loss.
Our jawbones have a couple different kinds of bone. The part of the bone that holds the teeth in place is called alveolar bone. This kind of bone sits on top of the basal bone of our top and bottom jaws. The interesting thing about the alveolar bone is that it only serves to hold our teeth in place. If we lose a tooth, the alveolar bone that used to support that tooth shrinks away.
Alveolar bone shrinks away differently with different people, but for the most part a person loses 40-60% of the alveolar bone around a tooth that is removed within the first year. 40-60%! Worse than that, the more teeth someone loses, the more alveolar bone they’ll lose!
You might be thinking “what’s the big deal? So I lose a little bone. I won’t even notice it.”
Well, maybe. If you don’t want to replace the tooth this might not be that big of a deal. If you replace the tooth with something removable (a denture or a partial) you’ll find that it continues to fit more poorly as you lose bone. If you replace the tooth with a bridge you might notice a space opening underneath the “fake” tooth. Or possibly the teeth holding the bridge in place begin to lose support as well.
“O.K., Doc. I get it. I don’t want to lose bone in my jaw. What can I do?”
I’m glad you asked! So it turns out that you can maintain that alveolar bone by replacing teeth with dental implants! Most people have heard that dental implants are a great treatment for replacing missing teeth. But did you know that placing a dental implant will help you maintain that alveolar bone? What a cool side effect!
When you place a dental implant it acts a lot like the tooth that was lost. The alveolar bone is maintained to hold the implant in place and you get tooth-like function and esthetics to boot! Dental implants kind of act like a time machine for your jaw bone by turning back the effects of alveolar bone loss!
Did you find this post timely? Restorative? 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.
Joint replacement surgery changes lives. For some people having a knee or hip replaced can end years of pain and struggle. The procedure has become quite common and many dental patients in our office have had it done.
Orthopedic surgeons and dentists have been telling themselves and their patients a story about artificial joints and the risks involved with dental treatment after having one. The story goes kind of like this:
Dental treatment causes oral bacteria to get into the bloodstream. These bacteria find their way to artificial joints and if they do, they can get horribly infected. Sometimes the infection can cause the artificial joint to become so bad that it fails and needs to be replaced. This is a serious and expensive side effect. The solution to this problem is premedicating with an antibiotic before you have any dental work done. That will make it so any oral bacteria that make it into the bloodstream are killed off before they can get to the artificial joint.
At first glance, this story makes sense. You definitely don’t want an artificial joint to become infected. Since we know that dental work can cause oral bacteria to get into the bloodstream, having dental work is clearly the problem. Right?
Well…not really. The story might not be true. In fact, there is no scientific evidence that artificial joints are more susceptible to infection after dental work. The story seems plausible but just doesn’t line up with our available evidence.
Some would say, “the complication of an infected joint is so severe that taking a dose of antibiotics is a small price to pay to keep us safe.” It turns out that there is also no scientific evidence that taking any particular antibiotic can keep an artificial joint from becoming infected. Furthermore, it’s worth mentioning that taking antibiotics isn’t a risk-free event, either. Allergic reactions can happen even in people who have had no reactions taking the same medication in the past. On top of that, every time you take an antibiotic it affects the natural balance of all the good bugs that inhabit your body as well. If you’ve ever gotten a yeast infection after taking an antibiotic, you know exactly what I’m talking about! Furthermore, the overuse of antibiotics promotes bacteria that become resistant to the antibiotics which is bad for everyone!
So this is what we’ve been battling with in dentistry. The standard for joint premedication has been take 2000mg (2g) amoxicillin an hour prior to your dental appointment. However, it is somewhat typical for a patient who is supposed to take their premedication to forget to take it. In fact, it happens often. At least weekly in my experience. So then you try and decide whether you should send them home and reschedule their appointment, give them the premedication at the office or just skip it. We sure could use a little bit of guidance from professional organizations, right?
In 2012 the American Dental Association (ADA) and the American Association of Orthopaedic Surgeons (AAOS) published some guidelines. Some vague guidelines. Frustratingly. Vague. Guidelines. You can read about these guidelines in a blog post I wrote back in 2012. Essentially the guidelines stated that although there isn’t any scientific evidence to support the use of antibiotics prior to dental treatment in joint replacement patients, each case should be considered separately. The opinion of the surgeon, patient and dentist were essentially equally valid. There was not a strong “you should do this” or “you shouldn’t do this” attached to the 2012 guidelines.
I have been trying to explain to joint replacement patients that the evidence goes against the need for premedication. However, these patients have been taking antibiotics for their artificial joints for years and years. They have been told by surgeons, dentists, hygienists and all sorts of other health care providers that they are truly at risk if they don’t. Many patients wanted to continue the antibiotics for dental treatment “just to be sure.” And who could blame them? Many dentists weren’t willing to take the (essentially nonexistent) risk either. Our policy had been that the patient just needed to get a letter from their orthopedic surgeon stating that the surgeon felt premedication was necessary and we’d write the prescription. This was a compromise that I was willing to make so long as we were stuck with these wishy washy guidelines.
In early January 2015, the American Dental Association finally weighed in strongly on the controversy:
“In general, for patients with prosthetic joint implants, prophylactic antibiotics are not recommended prior to dental procedures to prevent prosthetic joint infection. The practitioner and patient should consider possible clinical circumstances that may suggest the presence of a significant medical risk in providing dental care without antibiotic prophylaxis, as well as the known risks of frequent or widespread antibiotic use. As part of the evidence-based approach to care, this clinical recommendation should be integrated with the practitioner’s professional judgment and the patient’s needs and preferences.”
Not perfect, but pretty good in my estimation. The factors that may require premedication now are people who have previously had complications with infected artificial joints as well as patients with immune system compromise.
There should be rejoicing in the streets! Think of how much less often patients will have to take antibiotics! But alas, I’ve already run into patients with concerns. I completely understand this because it’s tough to change what we’ve been doing for so long. For now, we’re going to talk to patients and explain that they really don’t need antibiotics. But we’ll keep in touch with their orthopedic doctors, too. Change happens slowly, but I think the new guidelines are a big step in the right direction!
Did you find this post disjointed? Infectious? 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.