Management of Bleeding gums

 https://youtu.be/hQ-ChVpwUN8

 

Dentistry after Covid 19

We all know Covid-19 is a 'Black Swan' Event in our lives.. 
Dentists and Dentistry is in a period of Flux.
Its a time to Reflect, Revive and Restart.

                We being Healthcare providers are at the fore front of this and also at maximum risk to the infection.  Because of this risk, we have had to shut down our practices for a great financial loss to ourselves. Health is definitely above wealth.

            Now that we are now thinking ahead and thinking of restarting our practices in a matter of weeks from now atleast for emergency cases and less aerosol practice, 
the focus has now shifted to how to open up and still feel safe of the infection in our practice.

The guidelines have been issued and are being modified by DCI, IDA, CDC and various other bodies on what to do and what not. 

The only thing left is for us to make a choice - 

- How we should implement it. 
- Is it possible for all practices to implement all the guidelines. 
- Do we have such big practices that we can put up a traige area, changing room and waiting area and what not.
- Also we have different types of clientele. Is it possible for every patient to bear the cost of the new guidelines and that too for every visit. 

Or will it lead to a permanent change on how dentistry is practised. 
Will we see more of group practices or will it pave a way for Dental Insurance to enter in a big way.. 

What all problems will it lead to? Will the virus make a comeback because the guidelines were not followed properly.? Will it lead to persecution of the patient or the practice if a positive case is found out?

Well I guess we will have to wait for all the answers.. 

But Be positive. Remember - Whatever happens, happens for Good. 

Dental Care in times of COVID-19

In these Hard times, when almost half of the world is Locked down in homes, one thing that normally misses our attention is the Dental Care or Oral Health Care. 

That can change quickly if you suddenly have a cavity or pain and you struggle to find a dentist whos working.

Generally speaking - All that is required is to brush twice a day and Floss once. 

Diet Matters

What you eat is Very Important.. 

Avoiding excessive snacking — a habit that’s all too easy to adopt when dealing with the stress and boredom inherent in self-quarantining.

Starchy foods or drinks lead to acid in our mouths, which dissolves tooth surfaces.

The more often our teeth are bathed in these acids, the weaker and softer they become.

Good hydration also is important for oral health, dentists agree.

        Resist turning to unhealthy habits to manage your stress. Overindulging in smoking and drinking can be detrimental to oral health. Smoking inhibits the blood supply to your gums and increases your risk for gum infections. High exposure to alcohol can dry out the cells in your cheeks and gums. Chewing on ice, pen caps, or fingernails as a means of stress management can cause the teeth to chip or break.

Keep your toothbrush clean

If you suspect that COVID-19 is present in your home, disinfect your toothbrush.

Every time we flush the toilet, we generate an aerosol spray.  Most people leave their brushes and other toiletries merely inches away from commodes. Try to flush with the lid closed. Keep your floss pics, brushes, and tongue cleaners covered. Soaking them in a mixture of mouthwash and hydrogen peroxide also keeps them safe.

Dental care emergencies only

As COVID-19 spreads, the Indian Dental Association advised dental offices on March 16 to restrict their operations to emergency procedures only.

Dentists have been prohibited from providing nonemergency services, including aesthetic work, exams, cleanings, and fillings.

This accomplishes three very important things - It preserves the nationwide supply of personal protective equipment for our front-line heroes, prevents the spread of this virus through congregating in dental offices, and eliminates the need for dental emergency patients from flooding into emergency rooms that are better used fighting the virus.

Many dentists including us have turned to Online/Telephonic consultation to counsel patients by phone or video conferencing.

Dentists face one of the highest risks of contracting coronavirus, even greater than nurses or paramedics.  They literally work 6 inches away from our patients’ faces during dental procedures.

As a result, expect your dentist to take additional safety measures if you do have to make a visit for an emergency procedure — for your protection as well as the safety of the dentist and their staff.

When does a Tooth Need a Crown

               I got the idea for this post from teaching at the dental college. Different instructors seem to have different criteria for when its time to treatment plan a crown. I tend to crown teeth when there is sufficient tooth structure missing to put a tooth at greater risk for a future fracture. If such a tooth needs a replacement filling I usually recommend a crown instead, since this will tend to protect the tooth from the forces involved with chewing and protect the tooth from future harm. While replacing a large restoration with a new filling may be tempting, usually this is not optimal treatment. I believe that larger fillings fail more frequently than smaller fillings and when they do it places the tooth at an additional risk for the need of endodontic treatment or  tooth loss.

                  When treatment planning a tooth with a large failing restoration, I often find  that the tooth structure will not be sufficiently supported by another possibly larger new filling.When this is the case,  it's best to restore the tooth with a crown (or an onlay). I often explain this to my patient and add that when it's time to fix a restoration, it's best to fix it right and choose the best option available.

                  Patients sometimes counter that they cannot afford to  spend the money involved with having a crown made ( or would rather not). After hearing this I often point out that we can go ahead a place a large filling but if it may put the tooth at risk of developing a more significant problem. If their tooth later ends up needing a root canal or even needs to be extracted,  a significantly greater sum will be required.              I add this information because I need to confirm that my patient truly understands the reasons for my recommendation and that I have  informed consent to proceed with placement of a large filling. Often, after some back and forth conversation, my patient may change their mind and  have a crown made instead of a filling , but if  they don't, I can often place the large filling, with a clear conscience!

Do I really require twice a year cleanings?

            This is a question asked sometimes by "self paying " patients. They are worried bout the costs of two check ups and cleanings per year. Although no one "needs" two cleanings a year ( I mean, after all it's not a life or death decision), most dentists recommend this as our standard recall schedule.                     

                That's because we feel this schedule allows us and our patients a good chance of avoiding many dental problems and helps prevent bone loss that if left unchecked can cause their patients to lose teeth. With the cost of a single tooth implant somewhere between 20000 to 50000 , not going twice a year to your dentist might not save  money over the long haul ( Sometimes cheap is expensive and expensive is cheap?).

          Most people understand the importance of having oil changes at the frequency their car manufacturers recommend but sometimes this same logic isn't as convincing  where their teeth are concerned. It should be pointed out that taking care of ones teeth is probably more important than car maintenance. A  car can be replaced with a newer and better model, but really teeth really can not.                     Fortunately  missing teeth can be replaced with dentures, fixed bridges and implants, but these approximations  are not truly as versatile as ones own teeth .

                      Teeth that are well cared for both at home and by the dentist can last a lifetime! Why not "get with the program" and have twice a year cleanings? 

Why does my crown keep falling out?

Maybe it's not that into you.....? :)
              Being rejected by your crown hurts, especially when it was recently made and cost some serious money. Why does it happen? Usually either it has to do with the shape of the prepared tooth holding it or because the crown is ill fitting.

                For a crown to be retentive (resist the forces that may tend to remove it) the preparation has to be smooth and only SLIGHTLY tapered. It also has to be long enough to provide enough surface area to grab the cement. If the prepared tooth is too irregular, too short or too tapered, it may not have the proper shape to hold onto its crown.

                 Also, another possibility is that the crown can be cemented with a poor fit. In this case the crown does not hug the tooth well enough for the crown to stay put and since the crown is completely dependent on cement to stay. An analogy would be found in furniture making where most good furniture is made with dovetails, that increase the ability of the furniture to hold the wood together. Without dovetails, the pieces tend to work themselves loose more quickly. 
                 
                The same can be true with crowns, since their success is dependent on having a properly shaped tooth holding them and an intimate contact with it. The space between the crown and the tooth should be minimal (20-40 microns) in order for the cement achieve maximum holding power.

                   Most dentists faced with a permanent crown that comes out will first try to re-cement it. In my practice, I upgrade to a different permanent cement with more holding power. Unfortunately these cements do not always offer a long term solution and I am faced with the option of making the crown over.  When I do so I pay special attention to correcting any shortcomings in my tooth preparation and making sure that I take a perfect impression.

                  I should add a few  additional reasons that crowns can come loose. If the bite is high or just unfavorable, crowns can be more likely to come loose. Crowns do better when most of the occlusion is experienced along a  mostly vertical force vector and without much  of a horizontal component. Anterior teeth with deep over bites can experience a lot of horizontal forces on them and can sometimes be challenging to crown. Also some patients do have habits that are just not that friendly to crowns such as eating stale tootsie rolls or very hard and sticky candies. When chewed often these sweets tend to loosen even well fitting crowns


Dr. Pankaj Malhotra is a Periodontist & Implantologist in DELHI NCR region of INDIA, who maintains a practice in Noida. For more information about his Dental Practice please visit his website at www.dentalclinicnoida.in 

Do You Shop For your Dentist?

Almost every day my dental office gets a call from a potential patient shopping for a dentist. They ask for fees for certain procedures and often that is the end of the conversation. 

             I should note that my fees fall within the usual and customary range considered reasonable but for some persistent shoppers are too high. It seems that the internet has become the new Yellow Pages and potential patients are letting their fingers do the walking. It's not that hard calling a number of dentists and get a sense of the fees for the procedures that they will need. 

          Unfortunately, no information on the quality of the dental work can be gotten from these phone calls and shopping for dental work for some may be similar to shopping for furniture or other consumer goods. However teeth are not disposable and even implant replacements will not last forever.

         When I buy a piece of furniture, if I go to Ikea or any Local store, I expect to get a good price for what I buy, but I do not have the expectation that my purchases will last a lifetime or even ten years. It is asumed that there is a trade off involved with the inexpensive price paid but most of the time shoppers are  happy with their purchases . Many people like buying new furniture and actually like buying new pieces when they either tire of, or have to, replace them as they age.

            Teeth shouldn't be compared to furniture and restorations that are durable and preserve teeth for long periods of time are not always easily accomplished by dentists whose fees are the most reasonable. Although a higher price does not guarantee quality, it does tend to allow a dentist to to spend the time needed to create a thoughtful treatment plan and also the time to execute excellent restorative dentistry.
            I would like to quote a few examples here.. 

People dont mind paying 300 for Rs 30 popcorn in a theatre, but have reservations paying Rs. 300 consultation to a Dentist..

Also people dont mind paying 4000 bucks for a pair of jeans which shall last for 4-5 yrs and being worn for probably 100 times. While a crown of approximately the same value which you wear everyday and use it thrice daily lasts much longer than that..
             I guess the point of this post is to explain that price of services should not  be the primary method in choosing a dentist. Other attributes are quite important including but not limited to  recommendations from their patients, their skill level and their character.

Please contact me at www.facebook.com/dentistnoida
or https://plus.google.com/b/106703722934300581766

Sensitivity after a Crown placement

              There are two types of sensitivity that can commonly experienced after a crown is cemented. One is sensitivity to biting pressure and the other is sensitivity to cold (and or hot) liquids. If a patient is  experiencing either of these after a permanent crown is placed, then probably the best thing to do is to let their dentist know.

                  Sensitivity after a permanent crown is placed is not that uncommon. If a patient reports sensitivity, I check their bite, since a high bite can be irritating to the ligaments holding a tooth and can even cause pulpal sensitivity. A patient should be able to close there mouth comfortably without feeling any pain. If when they close their mouth (without chewing any food) they experience pain from a new crown, the bite should be adjusted.

              If a patient can comfortably close their mouths, but does experience pain on heavy chewing, I usually ask them to wait and see if the pain gets better with time. A crown cementation can sometimes irritate the pulp and with time this irritation can diminish. This can take months to go away and if a patient is willing, its usually best to wait. If I see them at their next recall, the tooth is still sensitive to chewing or when drinking cold liquids, I take a radiograph and if no pathology is evident, I usually try to get the patient to wait longer, since the only real other options are to perform a root canal on the tooth or to cut off the crown and place a temporary crown with a sedative filling. Which of these I would choose, if I feel the need to treat the tooth, is dependent on whether I believe the pulp has a reversible or irreversible pulpitis.

              Deciding whether a pulpitis is reversible is not always easy, but the prior history of the tooth has a lot to do with the decision. If a tooth was assymptomatic prior to me working on it initially, I am more likely to choose to remove a crown and place a temporary. If a tooth had a pre-existing crack in it or was symptomatic prior to me preparing it for a crown, I am more likely to recommend the patient visiting an endodontist and have a root canal done through the crown.

               I feel that the pulp is still vital and not infected, there is usually no harm in watchful waiting, since with enough time sensitive crowned teeth can calm down. I explain this to my patient and if the symptoms are bearable we often wait for the symptoms to slowly go away. If the symptoms are worsening instead, we can always choose the root canal option.

Why Dental Diagnosis are sometimes In-Exact.

              Even after after taking x-rays and performing a thorough clinical examination of a patient in pain, it is not always possible to make a definitive diagnosis in just one visit. Sometimes there are multiple possible causes for a patients discomfort. Often a patient having pain originating from one quadrant has multiple restorations and more than one can be  experiencing pain.

             Just last week a patient came in after a trip to Chennai complaining of pain. She hadn't slept all night. My clinical examination showed that the pain was coming mostly the area around lower back tooth , which had previously had a root canal, post and crown. The mesial papilla of the tooth  was swollen and painful. It had a pocket of 5-7 mm, and No drainage.  Clearly her pain could be due to a failing root canal or a fracture of one of her roots or also because of side teeth fillings. The x-rays taken were non conclusive.
                     To make the diagnosis more complicated the Patient had a bad cold and throat infection and fever. So the pain could have been worsened by Sinusitis or general malaise of the patient, which would definitely get better within 2-3 days with medication.

             I placed the patient on Antibiotics and it was decided that the best course of treatment was to do nothing more for the present but to speak with her in the following week to see if she was experiencing any improvement. If there was no improvement he could then check her again to see whether there was an actual tooth problem that required treatment.

                  Although patients in pain often want immediate relief, sometimes the best way to handle  a problem is to do nothing. This is especially true when the dentist is not sure what is causing the problem and there is a possibility that the symptoms will go away if the patient is given enough time. If the problem persists for more than a week or two , the patient should come back to the dentist in order to have him better diagnose the cause of the symptoms and often the source of the problem may become more apparent if given additional time.

What Should you do if your Filling Falls off...

If your filling falls off it is generally the time to call and schedule a dental visit. If your tooth is not hurting, it usually not so important to call your dentist, but you would be wise to seek an appointment within a week. Absence of pain is not a reason to delay seeing a dentist, since patients who report that a filling has fallen out can often have decay present or may have a piece of the tooth broken as well.

Once you visit your dentist, he will most likely need to take a dental radiograph or two so that he can diagnose the extent of the problem. If there is no decay present your tooth may just require a new filling. If decay is present, the dentist will need to clean it out prior to refilling the tooth. Bear in mind that in the event that the decay  has compromised the pulp, your tooth may require a root canal procedure and teeth with extensive missing tooth structure may be candidates for a crown instead of a filling.

Ask me no questions, and I'll tell you no lies.

               The title of the post is a saying by Oliver Goldsmith which personifies the subject i am writing upon.. 

           It seems like some of the patients that we see, read this quote before coming to the doctors.. Well as hard nuts as we are, we do ask questions and a lot of them at that.. 

            The details of the patient or as we call it the Case History of the patient which involves a set of questions to be put forward to the patient - starting from Name, Age, Address, occupation to the Complain and the the details about it and also about the other parts of the body and sometimes about the parents and children too.. 

          I dont understand why do some patients have to lie about these things and that also to a doctor.. the noble profession as we call it.. We are here to alleviate your misery not to gain some vital info about your house or family.. 

           Each and everyone of these questions is necessary to us for forming a diagnosis to your disease and to  treat you well. And if you tell lies about any of this you are hampering your own health and treatment and God forbid if some complication occurs, you shall never be able to forgive yourself.. 

         Even a phone number or your correct and full address is necessary sometimes.. We arent here to spam your phones with msgs or to flirt (female patients look astonished when we ask their age) so better we get all your details correctly and well informed then to play with your own lives..

            

          Here I would give you 3 examples of patients giving me wrong / incomplete information in the last 1 month and putting their lives or their children lives in danger..

1. A Female scheduled to undergo a surgery didnt tell us about her pregnancy until it gained a complication 1 week after the surgery was done.. She put herself under the stress of surgery, put herself under the Xrays and the complication later and then decided to abort the child..

2. A 8 yr old child who was scared to visit a dentist and had very little medical history suffered a Brain Stroke on the dental Chair and had to be immediately shifted to the hospital and underwent a Brain surgery..

3. A 28 yr old Patient fills up a form and details of all his brother and gets his treatment done just for faking a bill and getting reimbursed for it.. 

              So i request you to kindly give all your details as they are in your full knowledge to the doctors and we shall treat you to the best of our capability.. Remember we are all under Hippocrates oath and your information remains with us only..

Lastly, I pray to God that you dont have to come to us at all.. 

Keep Smiling.. 

Why Is Dental Treatment Expensive?

So am back after some hibernation with a sensitive topic which is on every patients lips whether in pain or not…

While Dentists are fortunate to be involved in a helping profession, they are also small businessmen who run a private for profit business.

Getting started in dentistry is expensive and can leave young dentist's with a large debt load of Lacs of rupees in debt. Opening a dental office is also expensive with real estate at all time high and rentals. Dental offices are costly to build and even well established dentists can feel financial pressures.

Fees are of intense interest to many people shopping for a dentist on the internet and often patients seem to be shopping for affordable dentistry. This is all well and good, but usually it is wise when seeking ‘bids’ to stay away from the low bidder (unless you’re our government?)

As one of my wise dental assistants once pointed out ‘Jitna sugar daaloge utni meethi cheez milegi”. Similarly where dentistry is concerned good work takes time and usually has a fee that properly reimburses the dentist for his time. And operating costs being the same in an area, quite naturally the ones doing at a low cost are cutting corners somewhere.

Most patients demand that their dentist stay current both with their continuing education and expect that their dentists use first rate materials. Similarly dental laboratories that dentists employ to achieve create beautiful and well fitted dental restorations are not inexpensive either. It is not surprising that that a high percentage of any dental fee goes to paying operating expenses. Most dental offices have operating overheads of 60-70 percent or more.

Salaries and benefits for well trained dental staff can be expensive since they expect compensation that is competitive with the market place and they most talented employees can easily find work with other dental or medical facilities.

Although dentistry can be treated like a commodity just like any other, it is an ART and also a science. Often in dentistry as in life, it not what you do that’s important, it’s how you do it! An excellent filling is better than a poorly fitted crown. Many dentists do things differently and invariably some offer better results than others. 

What are the best ways to maintain a healthy mouth?

This article attempts to explain some of the habits that people can develop that will help insure the ongoing health of their mouths. I will list my top ten list. Most of the these are no brainers, but still i see people not following them but here goes.
1.Take responsibility for your mouth!
2.Brush and floss your teeth on a daily basis
3.Schedule regular checkups and cleanings at the dentist
4.  Ask the hygienist or dentist to check your brushing and flossing technique
5.Do not chew on bones and ice cubes 
6.Wearing a night guard is usually recommended for patients.
7. Refrain from excessive drinking of carbonated sodas
8.Diet plays a large role in keeping our teeth healthy.
9.Do not wait until you have pain to visit your dentist
10.Find a good dentist (meee) and try to stick with them

Clearly there are many additional habits that play a role, including ., not smoking, and controlling acid reflux, I invite readers to add to this list with their own suggestions in the comment section.

DENTAL ONE liners.....

Dentists are incapable of asking questions that require a simple yes or no answer.

Did you hear about the dentist who planted a garden?
A month later he was picking his teeth

What does the dentist of the year get?...A little plaque

What game did the dentist play when she was a child?...Caps and robbers

What does a dentist do on a roller coaster?...He braces himself

What did the dentist see at the North Pole?...A molar bear

What was the dentist doing in Panama?...Looking for the Root Canal