The Tooth about Gum Disease Part II

Treating gum disease! Amongst dentistry, there is no more difficult disease to treat than periodontitis (which is the technical term for gum disease). I always tell my patients that the closest disease to gum disease, is Cancer.

Why cancer? Because it is a silent painless and usually slow progressing disease. By the time you notice there is a problem, the disease has become very far along and usually has destroyed a lot of your mouth. So just like cancer the key to success is early detection! As soon as we see signs of the disease we must treat and maintain.

The key word there is MAINTAIN. Just like cancer, gum disease has the tendency to relapse. So often do patients come in for treatment and then disappear for a several months or even years! When the come back for another visit, surprise surprise..... disease is BACK! So the key thing to remember is maintenance is the key to keeping gum disease away. How do we do that? Lets start by talking about treatment.

The first step of treatment is what is common called a "deep cleaning." I'm not sure how this term came to be because the technical term is called "scaling and root planing." But I believe people derived this term because it feels like the dentist (or hygienist) is doing the same thing except deeper.
However, although we use the same instruments, we have a very different mentality during this procedure. Going back to the cancer analogy, this is the "surgery" portion of the treatment. We have things we need to remove for the disease to resolve and we need to do it very aggressively.



Looking at this picture, it illustrates how far underneath the gums we need to go in order to remove the plaque and tartar(technically termed Calculus). Most of the time we are cleaning in between your teeth. There is very little room to operate and scraping these hardened plaques can be very taxing. Ultimately depending on the shape of the tooth and how much access we have, we may or not be able to get 100% of it off, but of course we all do our best.

Now here comes the key......

Once we get this stuff off, its very easy for it to grow back. Why? Because even though we have removed whats there, you still have a "deep pocket" that was formed when you originally got the disease. Food and debris easily gets lodged back into those areas and can quickly reform the tarter.

So once you have a deep cleaning done, standard brushing and flossing rules DO NOT APPLY!

You have to be even more diligent, brushing and flossing more thoroughly and often. I suggest patients to use extra aids to automate the process such as electric tooth brush and waterpik.



Keeping this stuff off isn't easy, and so you have to return to have your teeth cleaned every 3 months for what we call Periodontal Maintenance. And while its very similar to a cleaning as well, its more involved because we still have to retreat the pockets until the gums start to shrink back to health.

Sometimes no matter how hard we try, they still won't shrink won't back to health. Thats when we need to go to the next step. More on that next time.

The Tooth about Gum Disease Part 1

One of the most under appreciated parts of dentistry is treatment of the gums and surrounding tissue that holds the teeth. This areas in dentistry are called the "periodontium," and fall under the category of periodontics. But simply put this is the area that keeps your teeth tight in your mouth.




Most of gum disease can be understood with the above picture. On the left side we have a standard tooth with healthy gums. The gums are pretty attached and the brown mountain material next to the tooth is your jawbone. What dentists look for is the height of that bone on Xrays.

Now in the mouth dentists use this instrument call the periodontal probe:


Depending on who is using it, it can feel like someone is checking your gums or stabbing your gums multiple times. Often times the dentist will call out numbers while doing so. However gentle, he is trying to measure depth at which that "periodontal pocket" you see above is. The deeper it is, the more concerned the dentist is because 1) It shows how much bone has been eroded away and 2) It is extra hard to clean to deeper it gets for you and the dentist. Normal depths are 2 mm and 3 mm. 4 mm and above shows disease with anything 6 and above being very alarming.

So the big question is: WHY DO YOU CARE? Here are the reasons that you should care:

1) When severe enough, the bone will erode away to the point where your teeth will get loose, abscess and fall out. This is how people end up needing dentures even if they don't have cavities.

2. Periodontal disease has been linked to a lot of other very common and severe diseases. These include:

Heart Disease

Stroke

Diabetes

Premature and/or Low birth-weight babies

Cancer

So yeah that pretty bad stuff that is associated with something as trivial as gum disease. The reason for this is because gum disease is a disease that increases the overall inflammation in your body. Inflammation seems to be the big link for all of these diseases including cancer. We'll dive into treatment next post!

The Tooth about Dental Insurance Part 3: Discount Plans

The final type of "insurance" is called a Discount plan. This type of plan is what you will typically find if you do not have a company that has a group dental plan. Personal dental insurance is very expensive and so many companies will try to sell you this type of plan at a reasonable price and say it is insurance.

The truth is, this is NOT insurance. Some dentists will sign up with these discount plans and all they have to is agree to charge those patients certain fees for each procedure. The problem is that most of the fees are VERY SIMILAR to a normal dentist's fees. They may be slightly lower cost depending on how high end that particular office is. But for the most part, its just a big waste of money. So make sure if you are getting insurance and its not from you work, that you are actually getting a PPO insurance, or at least (dare I say) HMO =/ . Otherwise you won't get any coverage and you will have spent your money on nothing.

The Tooth about Dental Insurance: Part 2 - HMOs

Here's a big one. HMOs, they make me sad and most people that have them don't understand why. Well I'm going to break it down for you right now.

HMOs(Health Maintanance organization) or DMOs(Dental Maintanance organization) are lower cost insurance plans that look very similar to buyer on paper but they are vastly different in operation. Many companies have an option for either and HMO or a PPO so choose PPO ALWAYS. Lets explain why.

I'm going to explain everything to you from the Dentist's perspective: so you will see what I see when I tell you that I don't take your insurance. First off, in order to get any benefit from your insurance you can ONLY go to a set let of dentists that the insurance company provides. This is different than a PPO because with a PPO you can go to any provider you want but there are certain places that you will save money if you go to because they have signed a contract with the insurance company.

Second, as we have established with PPO insurance you will pay a percent of a service for example: 20% of fillings and the insurance will pay 80%. So in the end the dentist will get 100% of the fee (not really but its close). The HMO does the opposite, the patient will pay a small % fee but the insurance will only pay 20% not the 80% to the dentist. This means that the dentist will only get about 40% of the fee. Since dentistry runs at about a 60-70% overhead, that basically means that for a filling, the dentist will do it at a slight loss.
And that is not just for fillings: MOST PROCEDURES WOULD END UP DONE AT A LOSS. So basically you have to ask yourself, how can a dentist keep his doors open if his insurance forces him to do things at a loss. I will bring a specific example: for the exam cleaning and xrays, the dentist gets 0 dollars from any one: insurance or patient. So what happens? They will delay you forever to get your cleaning... because they don't even get paid for it.

So what do they have to do? They have to find ways to charge you, the patient, to make a profit. Thats why whenever you do go to one of the offices that accept your HMO insurance, they will try and sell you extra products and services. Whether or not these services are necessary are controversial but basically thats why I tell patients that even though I do not take their insurance, they may still save money by coming to my office.

There you have it. I do not like HMOs they force dentists to make tough decisions and the one who ends up suffering is you, the patient.

The Tooth about Dental Insurance: Part 1 - PPOs

Lets take a moment to step away and talk about non-teeth here. Lets talk about something you worry about more: money.

Dental insurance is complicated and tricky. Even with my years of experience dealing with it, its still difficult to know the in's and out's because each insurance plan is unique even within the same company (or carrier)! A lot of what I'm going to say is somewhat hush hush in the dental community. No one wants to take time to explain it to the patient because its complicated and it only discourages people from what the doctor is more concerned with: your dental health!

Lets start off with the basics. There are 3 types of plans that you will most likely encounter:

A PPO (Preferred Provider Organization) or DPO(Dental Plan Organization) is your typical insurance that most people are familiar with. They have an annual Maximum benefit limit which is typically between 1000-2000 dollars. They also have an annual deductible that you have to pay whenever you need anything more than a cleaning and exam. This is typically between 50 and 100 dollars.

Usually these plans will pay a particular fraction of your dental bill depending on what services you need. They typically pay more for smaller things like fillings and less for big ticket items like crowns. The remaining portion of the bill is called you "copay". The bottom line is they are trying to encourage you to get your cleanings and exams and discourage you from getting anything else. These copays are specially designed to discourage you from using your insurance so they can keep money in their pocket.

With that said, this is still the best type of insurance you can have among the three choices.
Here's some other facts that will play into effect:

- Many insurance plans will not pay for composite or white fillings in the back of the mouth (where most cavities occur). Insurance plans were first developed when there was mostly silver fillings and have resisted the increase in prices of more expensive white fillings. They will pay you and the dentist less which will result and higher than expected copays

- Many insurance plans have waiting periods before you can obtain services. They sometimes restrict only the bigger procedures like crowns but others may even restrict smaller ones such as extractions or fillings

- Many plans have what is called a "missing tooth clause" which basically states that they will not pay for any prosthesis for a tooth that was already missing when you enrolled in the plan. This includes bridges, implants and dentures (partial or full)

- Most insurance plans do not cover braces for adults so get them while you're young enough to get coverage!

- When you have a PPO insurance you can use it to see any doctor you choose. However there are some differences between doctors:

1) Some doctors have signed a contract with the insurance company which means they have to charge the fees that the insurance company dictates and they have to be imbursed but the insurance company directly.

2) Some doctors do not have contracts and have higher fees that the insurance expecting. So even though the insuance covers say 80%, they only cover 80% of whatever their fee for the area is. This could lead to large discrepancies. so if you're dental bill is large even though you have insurance you may have a doctor in this catagory

3) Some doctors will not accept your insurance directly paying them. This does not mean you cannot get coverage with them though. They often will send the claim to the insurance company and the insurance will send you a check. However, the dentist will expect the full fee up front this way. As a dentist this is actually the most fair way to handle things because often times the insurance company has lots of little clauses to deny coverage for certain things and we often have to eat that loss or send bills that never get paid. However, most people will not accept this and I understand.

The Tooth about Dental Implants

If you're missing a tooth and have been to a dentist recently. Chances are your dentist will have recommended having a dental implant. Theres a lot to say about implants but I'll go over the basics that will allow you to make the right decision for you.

DOES GETTING AN IMPLANT HURT? No. The implant placement procedure is about as painful as getting a filling. Very little pressure or sensations. Just lots of water and noises. Sit back and watch a movie. You will be sore after you go home so read my post on extraction to get some tips to help!

WHAT IS A DENTAL IMPLANT: A dental implant an artificial tooth made to be placed in the original spot of a missing tooth. It is made out of 3 pieces:

1. The replacement root or "Fixture". This is the part that involves surgery. After an old tooth is removed. The hole that it leaves is filled in with bone by your body. In order to put a new root in the spot, that bone needs to be removed to make space. The "fixture" is made out of titanium because that is the strongest material that the body does not reject. Most other prostheses in other parts of the body are also made from titanium.

2. The replacement tooth head or "crown" which is the part you will see and chew on. It is very similar to a crown that you get when you get a root canal or when you broke a tooth. It is typically a gold-metal hybrid coated in porcelein but sometimes it is made in all porcelein.

3. The abutment is the piece that connects the pieces 1 and 2. It is hand screwed into the implant. This is the piece that tends to get loose after several years of use. If you find that your implant is loose and moving, this is typically where the problem is. Its not a big problem, the dentist just needs to cut a whole through the crown to find the screw, tighten it with a wrench, and fill the whole. This usually does not have any pain associated with it.

WHY SHOULD I CHOOSE A DENTAL IMPLANT? To answer this question you basically have to understand the drawbacks of the other options. Whenever you need to replace a tooth you have 3 main options:

1) Partial Denture:  This prosthesis is typically bulky. It has clasps to hold onto other teeth and fake teeth to replace your missing ones. Because of its size, it tends to get in the way of your tongue and other tissue. It can generate sores. It can cause your jaw bone to receed from long term stress. It will catch food underneath. Overall its not sometime I would will on any of my friends or family. Its an affordable solution and something is better than nothing, but I would rather save my money for something more comfortable.

2) Bridge:      A bridge is basically putting a crown on the two teeth adjecent to the open space and attaching a fake tooth to them effectively "bridging" the gap. The best things about this solution are a) it feels very similar to having real teeth, since you are using  other teeth to support it, you still have similar chewing and sensations, b) its fast: the dentist can have this back to you in about 2-3 weeks. Whats the problem? Well as you can see, those two adject teeth are ground down quite a bit to what they used to be; and if they were perfectly good teeth, you just ground down about half of each healthy tooth. The other reason is this is a 3 piece unit which means that if any of these pieces fail, the whole thing fails. If you get a cavity on one of these teeth, you have to do it over again. If you lose one of the teeth to periodontal disease, you have to lose the whole bridge. SO its a good solution for the short term, but long term is has problems.

3) Implant: So basically the best thing about the implant is that its a stand alone soluation. No other teeth need be damaged and it relies on no other teeth. If you take care of it, you can take it to your grave. The only real problem with the implant is that it takes time. Usually somewhere between 3-9 months of treatment time. What are the factors that make up the time difference?

- Time to heal: The implant needs time to heal and "integreate" into your body. If you started to chew on it immediately, there is a good chance that it will never form bone around the implant and it would fall out.

- Do you have enough bone? If the tooth is lost for a long time the bone with atrophy away. This means the dentist may need to add some artifical bone around the implant to support it. This requires additional healing time

- Are you in good health? The implant site heals just like any other part of your body. Having health problems like diabetes can impair healing , requiring extra healing time.

-Do you smoke? If you smoke you can cause your gums and bone to not heal during this time. The dentist will tell you not to smoke, but not to say you will definately fail the implant if you do; it just really helps if you dont.

Jeffrey Chung DDS

The Tooth about Pulling Teeth

Its been a while since I had posted I apologize, I'll keep more regular update as much as possible!

"Pulling Teeth" or dental extractions get a lot of bad press just like root canals. The term "hard like pulling teeth" makes it seem like its a long painful process. Lets delve into what goes into a dental extraction so you understand the basics shall we?

DOES IT HURT TO HAVE YOUR TEETH EXTRACTED? Lets get the most pressing question out. No you should not feel pain during the actual extraction. Just like how root canals get a bad repuation, the history of pulling teeth being painful came from a time when our anesthetics were not as good as they are today. You should be completely numb during the time of the extraction and you should always ask for more anesthetic if you feel a sharp pinch. Don't worry after the initial pinch from getting numb you should not feel a 2nd, because the gums numb a lot more easily than the tooth.

Now for the confusing part.... where you won't feel pain, you will feel a lot of PRESSURE. Anesthetic cannot remove the pushing feeling of trying loosening and finally removing tooth. I'll go into whats actually happening next.

HOW DOES A DENTIST REMOVE A TOOTH? The term "pulling" a tooth is actually very misleading because there is very little pulling of the tooth. In fact if you were to attempt to pull your own tooth -- and you literally took a pair of pliers and pulled on the tooth, you would find that it does not come out unless you bench 250. Why is this? Because a tooth is held into your jaw by tiny fiber ligiments that attach directly into the bone. So basically the tooth is glued into the bone. If you want to remove something that glued shut, you don't just grab it and yank, you'll destory it and some of it will probably still be stuck! You want to loosen up the glue until its much weaker and then tease it our gently. This is how dentists remove teeth.

The process of extracting a tooth involves two things: loosening up those fibers and expanding the jaw bone. Bone is actually a little flexible (especially the upper jaw) and by wiggling the tooth or wedging an instrument between the bone and the tooth will allow it to "give" a little. While its wedged this is where you'll feel a lot of the pressure I was referring to before.

WHY ARE SOME TEETH HARD TO PULL? Okay, so while 90% of all teeth come out without much fuss, theres still 10% of them that put up a fight. So if your dentist is taking more than just 15 minutes getting your tooth out you probably have one or more of these:

- Highly decayed tooth below the gum line: nothing to grab on to, nothing to wedge against
- Very dense and unflexible bone: particularly common in african americans and the lower jaw
- A tooth that had a root canal and highly decayed: its brittle so it tends to shatter
- Curved roots - Try getting a crow bar out of cement and you'll understand
- Long Roots - More root = more fibers

WHAT DOES THE DENTIST DO WHEN TEETH DON'T WANT TO COME OUT? Okay STOP reading if you don't like details. At this point the dentist has realized this tooth is not going to simply loosen and come out, so he has to go to plan B. Usually plan B consists of moving the gums out of the way to see better, cutting the tooth into a few pieces so hes not trying to tackle all of it at once, or removing some of the jaw bone around the tooth so he can gain some extra tooth to lean on. Bottom line is you will be a little extra sore after the procedure is done.

WHAT IF THE TOOTH DOESN'T COME OUT? Now we're into the 1% probability range. Very rarely the dentist cannot get the tooth out because its either fused into your bone of the piece is so small, but when it does happen the dentist will usually choose to leave it in. Why? Because the damage he would need to inflict to you in order to get that little piece out is much worse than everything up to that point. What will happen? Either a) the body will just pretend its a piece of bone and intergrate it into your jaw, or b) you body will just gradually push it out until it comes out on its own.

TIPS for getting a tooth pulled:

- Take Ibuprofen 600 mg 4x a day 2 days prior to treatment (if you don't have health problems taking Ibuprofen. This will decrease pain and soreness during and after the treatment.

- If you feel any pain, ALWAYS ask for more anesthesia, don't "tough it out"

- Give yourself a few days to recover just to take it easy

- Don't feel that its going to be a big deal. Most of the time its a fairly simple procedure with minimal discomfort

Jeffrey Chung DDS