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. 

Why do my teeth keep breaking?

Some of my patients do seem to break a number of their teeth. There are probably a number of factors in involved. 
        First lets look at back teeth that break or crack. Often the teeth that break have fillings that undermine the existing tooth structure. Even a small filling placed close to the edge ( the mesial or distal of the tooth) can make a crack more likely to develop. Many of these teeth really should  have onlays or crowns placed to protect them.

             Another factor is the occlusion and frequency of night time clenching and bruxism ( many people do this at times while sleeping). Patients that have worn their teeth flatter so that there posterior tooth surfaces meet quite broadly during excursions often apply more force to their posterior teeth. These are people who have "cow bites" (Dentists term). Often when I examine these peoples teeth they have multiple posterior broad wear facets from their forceful grinding and chewing.

                Destructive habits , such as chewing on ice cubes, bones and other hard substances can also cause teeth to break. I had one teenaged patient who had no fillings in her teeth but kept breaking her teeth. It turned out she had a habit of chewing on to a pen top (kids do the darnedest things!)

              I have also observed that older patients, whose pulps have receded (no pulps in their clinical crowns) seem to be more likely to experience tooth fracture. This is especially true if the have a deep overbite involving their anterior teeth.

                Some dentists advocate changing the occlusion of patients by extensive tooth equilibration or by reconstructive dentistry. My solution is simpler.  For  most of these situations is to recommend that my patients wear a nightguard while sleeping that will protect their teeth and help eliminate destructive tooth to tooth contacts at night. This seems to be the least invasive choice and to my mind it is a "DO NO HARM" solution to the problem.

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.

Toothaches : What to do..?

Aching tooth

Although there are many causes for "toothaches", the correct procedure is to call your dentist. If you do not have one, call a friends dentist. If its after hours, call and take the appointment. Ok, but what to do until then?

The first thing to try is to take a pain killer such as Ibuprofen (Combiflam or Flexon) or Crocin. Both of these medications are not only good at cutting down inflammation but also provide pain relief for mild and moderate pain. Both are excellent to be used as first line medications for tooth pain. Do not take a stronger narcotic medication without trying one of these two. The sole exception would be for someone who  has a bleeding  problem or an allergy that can be caused by either of these drugs.

              It is not advisable to place tablets or clove inside the mouth in an attempt to alleviate the pain. Some patients try and holding this against the tooth in an attempt to stop the pain, but the medicines can cause burns in the gingiva. Rinsing frequently with warm saline solution can help in the event that a patient has a swelling in the gum.  It is not advisable to place a hot compress on the outside of the face, since this can draw an infection toward the skin of the face and can cause more swelling.

              Sometimes patients experience toothaches immediately after eating. Usually these people have a tooth or teeth with deep caries and eating can cause the teeth to throb. For these patients I advise not letting food come in contact with the painful tooth (teeth) since it can cause a worsening of the tooth ache. Often teeth with deep cavities and vital pulps will calm down on their own if left alone for a short period of time (an hour).

            If you are experiencing an "after office hours" tooth ache and cannot reach your dentist, a trip to the hospital emergency room is an option, since many emergency rooms have oral surgeons on call.

My crown broke, What should I do?

               If your crown breaks, you should call a dentist and get an appointment as soon as you are able. Hopefully your dentist will see you within a day or two. If they can't see you within a week, I would call a different dentist or better yet ask them 'nicely' if they can refer you to a good dentist who will be able to see you sooner.

               It is best to see a dentist soon, because it is often hard for a patient to evaluate the extent of his damage. Sometimes, a patient without much pain has sustainned a significant injury to a tooth. Fortunately, most times having your crown break isn't such a big a dental emergency. Most times when the patient is seen the crown either needs to be replaced or smoothed.

                Some times the remainder of the crown is sharp and can irritate or cut the tongue.
If the underlying tooth is exposed, sometimes the tooth is sensitive to air or cold liquids. That means the pulp inside the tooth is still alive(a good thing!). Although this is anoying and can be a pain, nothing will happen to the tooth in twenty four to 48 hours. Teeth do not decay in one week. It takes time for decay to develop

               Occasionally, when a patient calls and says "my crown broke", what actually has occured is the tooth under the crown has broken off and the crown has come out. This can be a bigger emergency. When the patient does come in, the remainder of the tooth has decay and sometimes it requires endodontic treatment. Often these teeth do not hurt, since the pulp is already dead. Some teeth have sustained vertical fractures and in a worst case scenario the tooth needs to be removed.

"If nothing hurts me my mouth must be OK, right?"

               This is a line of reasoning I hear from patients at my dental office too often. The patient is usually explaining why they have waited so long to come in and they explain that they assumed nothing was wrong since they had no pain. 

              Unfortunately most dental problems don't hurt until they are rather advanced .Most often dental interventions are best performed at the beginning of the problem when they can't be taken care more easily and inexpensively. 

             Sometimes by the time the patient becomes aware of a problem it is too late for the dentist to come up with a "simple fix". If a small cavity is detected a dentist can easily repair the tooth with a small filling, but a tooth with a large cavity may require a root canal or a crown or even an extraction. 

              Early detection of dental problems is key to keeping your mouth healthy and happy and frequent cleanings and check-ups allow dentists to achieve this worthwhile goal!  

          A HEALTHIER MOUTH FOR HEALTHIER YOU!!!  


For details please go to www.dentalclinicnoida.in   

Some Common Queries

Continuing with the common problems that patients have.. 

Today i have decided to come out with Root Canal Problems...

DOES ROOT CANAL HURT?

         This is the most common question that i am asked from everyone.. including Non Patients also.. and when i say it doesnt.. Patients become all the more suspicious..:)

 Root Canal Doesnt Hurt... Period... 

                  With proper anesthesia root canals can be a pain free procedure. Most teeth respond to regular local anesthesia injections. For Maxillary (upper teeth) dentists usually employ a combination of buccal infiltration and a palatal injection. For Mandibular teeth(lower teeth)a mandibular or mental block is used.

               Some teeth do seem to be hypersensitive at the time that root canal is started and patients still can report some sensitivity when a dentist attempts to access the pulp chamber. When this happens I sometimes use an additional intrapulpal injection in order to achieve complete anesthesia. Usually this injection does the trick for my patient and their endodontic procedure can be completed without further discomfort.

Can Successfully treated Root canal tooth experience occasional Pain/ Tenderness?

            Sometimes root canal treated teeth, that we consider a success, do have some "low grade inlammation ". The teeth are not infected but are not entirely without tenderness.

          Another possible explanation of continued symptoms it that some teeth have a small undetected crack and heavy chewing may cause some small movement of the the crack.

         If symptoms are disturbing sometimes a retreatment of the root canal can cause the tooth to become less symptomatic. After all, most of our check radiographs are two dimensional and do not show the root canal system as it acutally is. Small discrepencies in the 3-D fill also may be responsible for symptoms.

          Also for these types sometimes we do have an additional sitting or two.. But normally Root Canals are generally done in single Sittings.

Do ask me If any query on Dental problems is there... Would like to help it out.. 

Some Common Queries

I have decided to post some of the common queries which are regularly asked by the patients and also they get confusing answers while they keep asking the general population...

So lets get started.

What does it mean when someone says "I never have any cavities"? 

                    As a practicing dentist I sometimes encounter new patients, who have loved their previous dentist and are especially proud of how their teeth 'never need work'. 

                   I often hear this remark with a sense of dread; Although it can mean they have great teeth, it sometimes can be a tip off that their prior dentist was not detecting some dental problems. In such a situation, It can be awkward telling them the bad news, and I am always concerned that my potential new patient will not believe me If it turns out that they do have a number of dental problems.

                   After all they trusted and loved their old dentist and I am the 'new dentist in the area'. Often patients do not want to believe bad news and seek a second and third opinion ( often from their friends and family) before having a unwanted dental procedure.

Should Wisdom tooth ever get a Root Canal Done.?

                  The answer is sometimes. If a wisdom tooth has a deep cavity and has a pulpal exposure it can be a good candidate for endodontic therapy if it has erupted in a cleanable position and is in good function. Like other posterior teeth, after having a root canal wisdom teeth should be crowned. In my practice I recommend full metal crowns for wisdom teeth(and second molars), since the chewing pressure they can experience can make porcelain breakage more likely when porcelain fused to metal is used.

                If the wisdom tooth is not fully erupted or difficult for the patient to clean, then root canal is not the best option for dealing with a compromised pulp. Instead extraction is the best option. In this event, often the opposing wisdom tooth is extracted as well, since without an opposing tooth present, it may extrude over time.

Hope these are helpful for you... any more queries or any comments on these are surely welcomed...

Every day i shall be trying to post some query or other.. so Follow this blog regularly and follow the good dental habits too...