Dental Standard of care?

[The Captain]

I hope The Walk of the Penguin Mich will see this and chime in.  I'm not PM'ing because I think we will get some good information here.

DH and I moved recently and I finally found us a new Dentist.  Had my first appointment two days ago.

Night and day from my old dentist, whom I've been going to for at least 18 years.

Had my first oral cancer screening.  Ever.  Didn't realize (until Mich's post in another thread) that was considered a standard of care - how would I know?

They also measured something with my gums and charted that as well - guess again - yep first time for that also.

Took  a dozen xrays using digital technology.  My old denstist did bitewings with film.  There would be 5-6 of them.

Got a fluoride treatment.  When I asked about this (my old dentist told me it wasn't necessary for adults) I was told it was recommended for adults who had crowns.  Umm, I have several.

Speaking of which - yea - I have decay under one and will need to have it replaced, and there is an issue with a gap between the gums and the bottom of the crown on another - so another replacement.  New dentist did not look happy with the way the second crown was placed, but she didn't come out and say anything.

So what to believe?  I have a lot of money in my mouth and try to take good care of my teeth. 

I suspect this move may have been a good thing for one more reason.

[Tennesseer]

Aug 6, 2015 13:03:10 GMT -5 The Captain said:

I hope The Walk of the Penguin Mich will see this and chime in.  I'm not PM'ing because I think we will get some good information here.DH and I moved recently and I finally found us a new Dentist.  Had my first appointment two days ago.Night and day from my old dentist, whom I've been going to for at least 18 years.Had my first oral cancer screening.  Ever.  Didn't realize (until Mich's post in another thread) that was considered a standard of care - how would I know?They also measured something with my gums and charted that as well - guess again - yep first time for that also.Took  a dozen xrays using digital technology.  My old denstist did bitewings with film.  There would be 5-6 of them.Got a fluoride treatment.  When I asked about this (my old dentist told me it wasn't necessary for adults) I was told it was recommended for adults who had crowns.  Umm, I have several.Speaking of which - yea - I have decay under one and will need to have it replaced, and there is an issue with a gap between the gums and the bottom of the crown on another - so another replacement.  New dentist did not look happy with the way the second crown was placed, but she didn't come out and say anything.So what to believe?  I have a lot of money in my mouth and try to take good care of my teeth.  I suspect this move may have been a good thing for one more reason.

If they did not tell you why for the measurement of your gums, they were starting a baseline to see if your gums are receding (not good).  If they notice they have receded during your next visit, then they may suggest treating your gums to get them healthy again.

[lexxy703]

Captain I had the same experience 3 or so years ago when my old dentist retired & sold his practice to a new younger dentist. 

Digital X-rays that he showed me on the mounted computer screen.

Cancer screening.

The cleaning was done by ultrasound (I think that's what it is) not manually.

He also has this hand held wand that is like a video feed to the computer screen so when he was telling me he was concerned about one of my teeth he could show me on the screen what he was talking about.

I'm very happy with my new dentist.

[The Captain]

Aug 6, 2015 13:09:24 GMT -5 Tennesseer said:

Aug 6, 2015 13:03:10 GMT -5 The Captain said:

I hope The Walk of the Penguin Mich will see this and chime in.  I'm not PM'ing because I think we will get some good information here.DH and I moved recently and I finally found us a new Dentist.  Had my first appointment two days ago.Night and day from my old dentist, whom I've been going to for at least 18 years.Had my first oral cancer screening.  Ever.  Didn't realize (until Mich's post in another thread) that was considered a standard of care - how would I know?They also measured something with my gums and charted that as well - guess again - yep first time for that also.Took  a dozen xrays using digital technology.  My old denstist did bitewings with film.  There would be 5-6 of them.Got a fluoride treatment.  When I asked about this (my old dentist told me it wasn't necessary for adults) I was told it was recommended for adults who had crowns.  Umm, I have several.Speaking of which - yea - I have decay under one and will need to have it replaced, and there is an issue with a gap between the gums and the bottom of the crown on another - so another replacement.  New dentist did not look happy with the way the second crown was placed, but she didn't come out and say anything.So what to believe?  I have a lot of money in my mouth and try to take good care of my teeth.  I suspect this move may have been a good thing for one more reason.

If they did not tell you why for the measurement of your gums, they were starting a baseline to see if your gums are receding (not good).  If they notice they have receded during your next visit, then they may suggest treating your gums to get them healthy again.

Actually they did take the time to explain it to me, I'm just not sure I can do it justice trying to repeat it.

Something about soft gum tissue and hard gum tissue and how many centimeters? of soft gum tissue should be around the base of the tooth to be considered healthy. Because I have so many crowns (and old ones at that) I have some recession already. It's something I've been a little concerned about to be honest, but they told me my gums were well within normal parameters.

[Tennesseer]

Aug 6, 2015 13:12:43 GMT -5 The Captain said:

Aug 6, 2015 13:09:24 GMT -5 Tennesseer said:

If they did not tell you why for the measurement of your gums, they were starting a baseline to see if your gums are receding (not good).  If they notice they have receded during your next visit, then they may suggest treating your gums to get them healthy again.

Actually they did take the time to explain it to me, I'm just not sure I can do it justice trying to repeat it.

Something about soft gum tissue and hard gum tissue and how many centimeters? of soft gum tissue should be around the base of the tooth to be considered healthy. Because I have so many crowns (and old ones at that) I have some recession already. It's something I've been a little concerned about to be honest, but they told me my gums were well within normal parameters.

Did they by chance recommend using ACT Restoring mouthwash or a generic? It helps restore minerals to soft spots and strengthen the enamel (though it does not restore enamel as some believe). I use it. Not sure how much it helps but my mouth at least smells fresh.



If you do decide to by ACT Restoring, double check the bottle you are buying. When I bought the first bottle it said to use once a day. When I ran out of it, I bought another bottle but it had more fluid ounces in it and it said to use twice a day. It was also just a dollar or two more than the smaller bottle. I though it was a good deal (price wise) until I later discovered the larger bottle with more fluid ounces had less fluoride in it than the smaller bottle. Hence using the larger bottle twice a day.

[The Walk of the Penguin Mich]

If you don't know, then all of these seem like they are 'extras'.  

Every single time I've gone into the dental clinic, they ask me how my general health is.  This is because there is a lot of information where they now know that your general health and oral health are intertwined.  If you have diabetes, they can do things prophylactically to keep its impact to a minimum.  If you have heart disease, they are going to be VERY concerned with any inflammation that they see - because it is known that it can exacerbate heart disease.  For me, I get asked as to my prostheses and whether or not I've taken my antibiotics (I have to take 2 g of Keflex before getting my teeth cleaned to prevent infection of the prostheses).  I don't want do deal with that again (even though this was not what caused my infection), so am not about to take a chance with it.  They also take my BP.

Next they do an oral cancer screening.  Finding oral cancer early, like many others, is better found sooner than later.  As they know what to look for and you normally cannot see the places they look.  They should also run their fingers over your gingiva to feel for any lumps.

What they did was a perio charting for you.  This is the distance between the top of your gingiva to the bottom of your gingival pocket.  Optimally, this needs to be 2-3 mm.  4 tends to be spot that they look at carefully.  I have a crooked tooth that flips between 3 and 4.  Mostly 3, so they just keep an eye on it.  If you have anything greater than 4, then they start to become concerned.  This means that you have periodontal pockets, which means that the bone is receding from your teeth.  This is normally caused by inflammation and bone destruction = periodontal disease.  When the bone is gone, the tooth support is gone and you lose your tooth unless it's treated.  To treat it, normally they do a 'deep cleaning' where they get down and scrape all the crud (bacteria) out of the pocket that causes the inflammation.  There are also some inserts of antibiotic impregnated threads that they can put down there, we did some studies on this but not sure where those have gone.  If too much support is gone from the tooth, no amount of deep cleaning will help.  As it is a source of infection, it's likely healthier for your other teeth (and general health) to pull it.

Now, at the same time they take the measurements, they are also looking for whether you have bleeding on probing.  If you have red gingiva and bleeding but no pockets, this is called gingivitis.  You need to do better at brushing and flossing as this is reversible.  Gingivitis does not always turn into periodontitis, but periodontitis is always preceded by gingivitis.  Optimally, there should be no blood in your mouth when you brush your teeth or they clean them.  I can't remember the last time my gingiva bled when my teeth were cleaned.

Xrays, I would get bite wings once each year (normally 2 on each side) and they had a panoramic imaging machine - which likely did the same thing that your dozen digital xrays did - every 2-3 years.  When I went to a new dentist, they didn't have the panoramic imaging so took a dozen xrays, like you.  I went to another dentist and (thankfully) the dentist transferred those xrays to my new dentist so they didn't have to take new ones.

The fluoride treatment makes sense.  And it is VERY important that you get good margins (the area where the top of the crown hits the gingiva) on crowns.  The fact that you didn't means that they are not good fitting.  A poor margin opens that tooth up to disease because it does not protect the supporting tooth underneath.  Having a poor fitting crown is laziness on the part of a dentist.  Either they did not get a good mold of your mouth or the lab is crappy.  Neither are acceptable.

Hope this helps explain things.  

[The Walk of the Penguin Mich]

Aug 6, 2015 13:09:24 GMT -5 Tennesseer said:

Aug 6, 2015 13:03:10 GMT -5 The Captain said:

I hope The Walk of the Penguin Mich will see this and chime in.  I'm not PM'ing because I think we will get some good information here.DH and I moved recently and I finally found us a new Dentist.  Had my first appointment two days ago.Night and day from my old dentist, whom I've been going to for at least 18 years.Had my first oral cancer screening.  Ever.  Didn't realize (until Mich's post in another thread) that was considered a standard of care - how would I know?They also measured something with my gums and charted that as well - guess again - yep first time for that also.Took  a dozen xrays using digital technology.  My old denstist did bitewings with film.  There would be 5-6 of them.Got a fluoride treatment.  When I asked about this (my old dentist told me it wasn't necessary for adults) I was told it was recommended for adults who had crowns.  Umm, I have several.Speaking of which - yea - I have decay under one and will need to have it replaced, and there is an issue with a gap between the gums and the bottom of the crown on another - so another replacement.  New dentist did not look happy with the way the second crown was placed, but she didn't come out and say anything.So what to believe?  I have a lot of money in my mouth and try to take good care of my teeth.  I suspect this move may have been a good thing for one more reason.

If they did not tell you why for the measurement of your gums, they were starting a baseline to see if your gums are receding (not good).  If they notice they have receded during your next visit, then they may suggest treating your gums to get them healthy again.

No, it's not that your gingiva is receding that is important, it is that the bone supporting your tooth is receding.  It causes a pocket deeper than the 2-3 mm it should be, and demonstrates that the bone is being degraded by inflammation.

[The Captain]

Margins, that's the word they kept using.  I couldn't remember.

Thanks The Walk of the Penguin Mich.  I liked my old dentist so much it's kinda hard to learn he may not have been as good as I thought he was.  I'm especially pissed about the fluoride thing because it may have prevented needing to get one of the crowns replaced.  It's not gonna be cheap.  There's also a small chance there's not enough tooth left to put a new crown on.  We'll cross that bridge (get it - bridge) when we get there.

I'll probably end up spending close to what we're spending on DD's braces this year on my mouth.

Oh, and thanks for reminding me about the antibiotic thing.  DD has a small septal defect and at one time the standard of care was to go on low dose antibiotics (like you) before dental work.  I'm told that is no longer the case but I want it in her chart, just in case.

[The Captain]

Aug 6, 2015 13:21:58 GMT -5 Tennesseer said:

Aug 6, 2015 13:12:43 GMT -5 The Captain said:

Actually they did take the time to explain it to me, I'm just not sure I can do it justice trying to repeat it.

Something about soft gum tissue and hard gum tissue and how many centimeters? of soft gum tissue should be around the base of the tooth to be considered healthy. Because I have so many crowns (and old ones at that) I have some recession already. It's something I've been a little concerned about to be honest, but they told me my gums were well within normal parameters.

Did they by chance recommend using ACT Restoring mouthwash or a generic? It helps restore minerals to soft spots and strengthen the enamel (though it does not restore enamel as some believe). I use it. Not sure how much it helps but my mouth at least smells fresh.



If you do decide to by ACT Restoring, double check the bottle you are buying. When I bought the first bottle it said to use once a day. When I ran out of it, I bought another bottle but it had more fluid ounces in it and it said to use twice a day. It was also just a dollar or two more than the smaller bottle. I though it was a good deal (price wise) until I later discovered the larger bottle with more fluid ounces had less fluoride in it than the smaller bottle. Hence using the larger bottle twice a day.

I'll have to give it a try. It's stupid how much time I spend on my mouth as it is, and I still get cavities . 

1.  Brush
2.  Get little bottle cleaner brushes out and clean bridges and in areas where floss doesn't work so well
3.  Floss
4.  Waterpick bridges and rest of mouth.

DH isn't as "obsessive" as I am and the dude doesn't have one single cavity.     

[lexxy703]

My old dentist recommended I use ACT restoring.  My new dentist recommended I also get a waterpick.  I have yet to do that.

[The Walk of the Penguin Mich]

DD has a small septal defect and at one time the standard of care was to go on low dose antibiotics (like you) before dental work. I'm told that is no longer the case but I want it in her chart, just in case.

It is functional?  

After hearing what happened to one of the local firemen, even though it is no longer the standard, my dentist insists on antibiotics.  Dentist had fireman as a patient and he needed a root canal.  Fireman also had a heart murmur.  He called the fireman's cardiologist and they discussed whether or not prophylactic antibiotics were necessary and the cardiologist told him that it was not necessary.  Turned out, the fireman wound up with infective endocarditis from the root canal that destroyed his heart valves.

I came in after this happened and we discussed my needing prophylactic antibiotics after my re-replaced hips.  Even though the standard of care is not after 2 years, his attitude now is lifetime and makes sure I have a prescription and won't touch me unless I've taken them.  It may be overkill, but at least HE will know that he has done everything he could to prevent something from happening.  I agree with him.

[The Captain]

Aug 6, 2015 14:01:47 GMT -5 The Walk of the Penguin Mich said:

DD has a small septal defect and at one time the standard of care was to go on low dose antibiotics (like you) before dental work. I'm told that is no longer the case but I want it in her chart, just in case.

It is functional?  

After hearing what happened to one of the local firemen, even though it is no longer the standard, my dentist insists on antibiotics.  Dentist had fireman as a patient and he needed a root canal.  Fireman also had a heart murmur.  He called the fireman's cardiologist and they discussed whether or not prophylactic antibiotics were necessary and the cardiologist told him that it was not necessary.  Turned out, the fireman wound up with infective endocarditis from the root canal that destroyed his heart valves.

I came in after this happened and we discussed my needing prophylactic antibiotics after my re-replaced hips.  Even though the standard of care is not after 2 years, his attitude now is lifetime and makes sure I have a prescription and won't touch me unless I've taken them.  It may be overkill, but at least HE will know that he has done everything he could to prevent something from happening.  I agree with him.

See this is where I get pissed, (not at you).  I'm a reasonably intelligent person but I don't even know what questions to ask.

DD's cardiologist never mentioned the word "functional" or anything specific.  We were told to wait until DD was 4 in the hopes it would close on it's own.  It didn't.  We are told the risk of surgery to close it would be greater than the risk of just leaving it alone. She can participate in sports as normal, do everything normal, but before anything invasive is done she's supposed to go on antibiotics.

Then when she was about 8 (and I was freaking out cause she was losing teeth) we were told the standard of care was changed and we didn't need to worry about antibiotics with dentistry.

Her pediatrician is aware of this as well and has not advised us to do anything special.

[bean29]

I am going to have a crown done soon. I have several others, but they were sent out to a lab and a temporary crown was placed.

This is a new dentist taking over my old dentist's practice. he said they now can make the crowns right in the Dental office. Is this better or worse than the old school way?

[The Walk of the Penguin Mich]

Aug 6, 2015 14:12:17 GMT -5 The Captain said:

Aug 6, 2015 14:01:47 GMT -5 The Walk of the Penguin Mich said:

DD has a small septal defect and at one time the standard of care was to go on low dose antibiotics (like you) before dental work. I'm told that is no longer the case but I want it in her chart, just in case.

It is functional?  

After hearing what happened to one of the local firemen, even though it is no longer the standard, my dentist insists on antibiotics.  Dentist had fireman as a patient and he needed a root canal.  Fireman also had a heart murmur.  He called the fireman's cardiologist and they discussed whether or not prophylactic antibiotics were necessary and the cardiologist told him that it was not necessary.  Turned out, the fireman wound up with infective endocarditis from the root canal that destroyed his heart valves.

I came in after this happened and we discussed my needing prophylactic antibiotics after my re-replaced hips.  Even though the standard of care is not after 2 years, his attitude now is lifetime and makes sure I have a prescription and won't touch me unless I've taken them.  It may be overkill, but at least HE will know that he has done everything he could to prevent something from happening.  I agree with him.

See this is where I get pissed, (not at you).  I'm a reasonably intelligent person but I don't even know what questions to ask.

DD's cardiologist never mentioned the word "functional" or anything specific.  We were told to wait until DD was 4 in the hopes it would close on it's own.  It didn't.  We are told the risk of surgery to close it would be greater than the risk of just leaving it alone. She can participate in sports as normal, do everything normal, but before anything invasive is done she's supposed to go on antibiotics.

Then when she was about 8 (and I was freaking out cause she was losing teeth) we were told the standard of care was changed and we didn't need to worry about antibiotics with dentistry.

Her pediatrician is aware of this as well and has not advised us to do anything special.

This is where you need to have a discussion between the cardiologist, her ped and your dentist. What happened to me (and the fireman) was phenomenally rare, but it happened. The risk is very small, but the repercussions of it happening are life altering.  I'm not exactly sure what your daughter's heart defect is, but if she has less than normal flow of blood through the heart and blood is allowed to pool, then it increases her risk.

The standard of care for me is no antibiotics too.  However, I have a dentist that disagrees with the ADA and I have an orthopedic surgeon that disagrees with the AAOS (the governing bodies of their respective organizations) so I don't have to fight this battle in the immediate future.  But I am under no misconceptions that I won't have this fight in the future.  Already having a double prosthetic infection helps me present my case.

It's not an easy problem to solve.  Those who make these decisions make them intellectually.  However, I'm the one dealing with the fallout, not them.  I look at it (and understand that) from another perspective and one that is far more emotional.  But then, I was the one who was left disabled after a year of hell.

[The Walk of the Penguin Mich]

Aug 6, 2015 14:18:32 GMT -5 bean29 said:

I am going to have a crown done soon. I have several others, but they were sent out to a lab and a temporary crown was placed.

This is a new dentist taking over my old dentist's practice. he said they now can make the crowns right in the Dental office. Is this better or worse than the old school way?

Both, I think.  

If the crowns don't fit right, the dentist doesn't have to remake the mold (are they being made digitally?), replace the temp crown and send it away to be remade.  

OTOH, I have no idea of the quality of it.  I know that some dental technicians can be utter artists in making crowns that fit, it's a talent and a skill that experience brings.  I'd probably be asking a lot of questions as to differences in materials used.

[The Walk of the Penguin Mich]

Aug 6, 2015 14:07:28 GMT -5 @sroo4 said:

My dentist is 'old school'  but here's what I have done during a regular exam. 

1. Cancer screening
2. Bitewing xray
3. Cleaning - they ask if I'm ok with the superduper water descaler (I am so they do it)
4. Polishing
5. Discussions about any problems- my issue is cavities.  According to my dentist I have very very very deep grooves (natural) in my molars that are next to impossible to keep clean.  I also have tooth crowding and some oddly set teeth*  I generally have one small filling that needs to be done.  She also watches for cracking as I am a jaw clencher and the aforementioned sharp molars.  The last time I went in she asked me if I had any pain or problems since the last visit.  When I told her I did,  but I was pretty sure it was my sinus' acting up she gave me a bit of a look until she took the xrays.   That's when she realized that my roots darn near touch my sinus cavity so any swelling there will make my teeth hurt. 



*I have come to realize that I had some very questionable dentists as a child/young adult.   My canine teeth on top started to grow over my baby teeth, and my dentist didn't really feel the need to pull my baby teeth.  So now my top canines sit higher than the rest of my teeth and bit forward... they don't stick out,  but they are definitely different.  I also didn't know you could get your teeth cleaned and not bleed from the gums.   I never had any problems with my gums (as in they weren't puffy or didn't bleed when I brushed) but when the hygienist would use that little pokey thing she wasn't quite happy until I was bleeding. 

No perio exam?  Bite wing xrays are of your molars only.   How does your dentist know what's happening under the gingiva of your incisors?

[wyouser]

How appropriate. A dental thread today...and today is National Fresh Breath Day!.. Captain, your new dentist appears to doing a thorough check up!

[The Walk of the Penguin Mich]

Aug 6, 2015 14:51:15 GMT -5 @sroo4 said:

Maybe you need to define the perio exam for me... is that the 3d xrays?    She manages to get all my teeth when she xrays.  

Perio exam is when they measure pocket depth.  They take 3 measurements around each tooth and call out a number.  Someone records the number on a tooth chart.  Optimally, you want 2s and 3s.  4s mean that you may or may not have something going on, but it should be watched.  Greater than 4 in a lot of spots means you have some sort of inflammatory process that is destroying bone and if you want to keep your teeth, you need to do something about it.

The measurement measures the distance between the bottom of the pocket bone to the top of the gingiva.  The deeper the pocket, the more the probe goes to the bottom and the higher the measurement.  This delineates loss of bone - which supports the tooth. 

You can see this in xrays when it is extreme, but small changes (when you want to jump on the issue) don't show up quite as well.  At this point, a loss of 1 mm of bone, going from 4 - 5 mm is significant but probably not seen on an xray.

[The Captain]

Aug 6, 2015 13:54:02 GMT -5 lexxy703 said:

My old dentist recommended I use ACT restoring.  My new dentist recommended I also get a waterpick.  I have yet to do that.

I was a bit miffed to find my new dentist sells waterpick's for $25 bucks less ($75) then the best price I could get at Kohls. 

Ah well.

[lexxy703]

Aug 6, 2015 15:33:45 GMT -5 The Captain said:

Aug 6, 2015 13:54:02 GMT -5 lexxy703 said:

My old dentist recommended I use ACT restoring.  My new dentist recommended I also get a waterpick.  I have yet to do that.

I was a bit miffed to find my new dentist sells waterpick's for $25 bucks less ($75) then the best price I could get at Kohls. 

Ah well.

Mine doesn't sell them just recommends that I use one.  If he sold them I would have bought one.  It is pure laziness on my part that I haven't purchased one yet.

[The Walk of the Penguin Mich]

Aug 6, 2015 15:33:45 GMT -5 The Captain said:

Aug 6, 2015 13:54:02 GMT -5 lexxy703 said:

My old dentist recommended I use ACT restoring.  My new dentist recommended I also get a waterpick.  I have yet to do that.

I was a bit miffed to find my new dentist sells waterpick's for $25 bucks less ($75) then the best price I could get at Kohls. 

Ah well.

They can get really good deals.

Waaaaay before Sonicares got so popular, we had a Philip's booth at our research meetings where we could make personal purchases for about $35 each.  I bought a LOT here.  Not long ago, I was at another dental meeting (for some reason, Philip's stopped showing up at the IADR) and they were there.  I bought new Sonicare heads for about half of the best price I could find anywhere (I want to say about $7 for 2 heads), so now have a lifetime supply of them!

TD uses a Waterpik because he has a lot of crowns too.  They do a really good job for him getting under the crowns.