Creating the Ultimate Doctor-Hygiene Patient Exam

August 4th, 2014

By Karen Davis, RDH, BSDH

Dental Clinic. The dentist explaining to his young patient how t

It seems as though the examination portion of the hygiene visit often lends itself to increased stress, but it doesn’t have to. Creating an ultimate experience is realistic and implementation of these tips will assist.

1.  Let go of the idea that a prophylaxis appointment is all the patient needs!

In practice after practice, dental hygienists are desperately attempting to educate the patient, change behavior, scale all calculus, remove all stain and plaque, perform and record periodontal evaluations, update radiographs, apply fluoride, identify restorative concerns, and so on, all in ONE appointment that lasts 45 – 60 minutes, IF you get started on time!  Sound impossible?  It is. The American Dental Association has done a great job defining the difference between a prophylaxis, scaling and root planing, and periodontal maintenance.  Early in the appointment, if data collected reveals a periodontal diagnosis, it is easy to determine which patients need additional therapy and which patients need preventive care.

2.  Don’t wait until the last five minutes of the appointment to have the exam

In most busy dental practices, waiting until the hygienist is completely finished before notifying the doctor for an exam is almost a guarantee of running behind. Notifying the doctor once data has been collected and potential treatment discussed enables the dentist to look for a natural break in a procedure, interrupt the hygienist during his or her treatment, perform the examination, then both return to completion of their treatments.

3. Use visuals to replace wordy descriptions

Patients will understand and retain information significantly better if audible and visual learning takes place together.  Instead of us doing all of the talking (while working on the patient with sharp instruments) clinicians should intentionally let  “pictures speak 1000 words”.  Intraoral pictures, before and after pictures, educational pamphlets, radiographic pictures, periodontal records, Caesy ®, etc., all assist in the co-discovery process necessary for patients to really understand and desire what we recommend.

4.  Sit the patient upright for communication

Contrary to how most of us commonly communicate with patients in the treatment room, if we are willing to pause, sit the patient upright to describe conditions and discuss possible treatment, we find we actually have to say less, because the patient’s ability to hear and retain information is significantly greater with the use of good eye contact and body positioning.  Sitting the patient upright also allows the patient to feel more comfortable and ask questions and enables us to become the listener. Most patients will not proceed with treatment until their questions have been answered!

5.  Ask for a commitment to treatment

In the treatment room, where value is created and treatment recommendations are made, prior to handing the patient off to an administrator, clinicians need to ask a closing question such as, “So, James are you ready to get started?” Even when the product we are “selling” is optimal oral health, asking the patient to make a commitment fosters ownership of their health.

 

Davis

Ms. Davis is founder of Cutting Edge Concepts®. She is an international speaker and practices dental hygiene in Dallas, Texas. She has served on numerous advisory boards, is considered a key opinion leader to many corporations in the profession and is recognized by Dentistry Today as a “Top Clinician in Continuing Education”.  She is an accomplished author related to her passion of practicing on the cutting edge of the profession. Ms. Davis is a member of the American Academy of Oral & Systemic Health and the American Dental Hygienists’ Association.

 

You and Your Sleep Deprived Patient

July 16th, 2014

By Dr Uche Phillip Odiatu BA, DMD 

woman in bed awakening

You thought you had it all figured out –  during your new patient exam health history section you ask patients what meds they take; if  they have ever been in a motor vehicle accident; and some dentists ask about specific supplements their patients are taking. Well, that is only part of the equation when it comes to your patients’ health history. Current sleep research has shown if you are regularly sleeping less than 7 hours a night you are more likely to suffer from cardiovascular disease, stroke, cancer, diabetes and any number of other inflammatory conditions. Think gingivitis and periodontitis.

Most dental professionals are aware of sleep apnea and its grave consequences on the heart and brain. If sleep apnea is severe a CPAP machine is prescribed by the patients’ health care professional. If the diagnosis is mild a MAD or Mandibular Advancement Device can be made by the dentist. This article is not about obstructive breathing issues but about patients who simply do not get to bed on time, work shift work or have evening habits that disturb their sleep quality and quantity. If you read this article you will receive insightsthat will help you expand your New Patient exam questions or it will support your own healthy living goals.

“There is plenty of compelling evidence supporting the argument that sleep is the most important predictor of how long you live, perhaps more important than whether you smoke, exercise or have high blood pressure or cholesterol levels” ~ Dr William Dement, one of the world’s most prominent sleep researcher and founder of the Stanford University Sleep Disorder Clinic.

  1. Current sleep research has shown that 4 out of 10 people reported they sleep poorly.
  2. 20-40% of Americans work some type of evening or overnight shift.  Michael Howard PhD has reported that people who do shift work spend most of their waking time in a “jet lag” state.
  3. There is an important part of your brain –SUPRACHIASMATIC NUCLEUS – that  is your brain’s circadian clock which does not function well with cross country travel / time zone changes, poor sleep habits, nights shifts, sleep apnea, etc .
  4. When working into the wee hours of the night, cross time zones with cross country air travel to “four on four off” shifts the body’s reserves do not get replenished. From wound healing to trying to recover from a cold or a flu, a sleep debt can bankrupt your good intentions.
  5. Cumulative sleep debt costs you and your patients. People with disrupted sleep from rotating shifts have 3 times as many GI problems such as constipation, abdominal pain, heartburn and reflux (think acid erosion of lower molars) than those who have regular day time work hours
  6. REM (rapid eye movement) sleep is a vitally important part of your night. For optimal emotional health, adults need approximately 100 minutes of REM a night. (This can only be measured in a formal sleep study – called POLYSOMNOGRAPHY).  REM sleep has also be shown by UC Berkeley experts to help processes stressful memories and experiences and bring enhanced well-being into your life. Are you thinking of certain patients with bruxism habits?
  7. Research has shown that visual learning , especially learning to do NEW things gets consolidated while you are asleep – especially during REM sleep. A 2010 Harvard study on memory had their 100 volunteers do a test on finding their way around a maze on a computer. During a five hour break some stayed awake another group napped before taking the test again. The group who napped did the maze 162 seconds faster than the ones who stayed awake when doing the test again. Those who actually dreamed while napping did  their second test maze 225 seconds faster. TAKEAWAY for dentists on three day intense implant courses or leadership training? Take a nap midday or after an 8 hour workshop to internalize, consolidate the information and make it your own.
  8. A prominent Canadian dental journal Oral Health had a cover story demonstrating a relationship between obesity and periodontitis. This relationship was based on the inflammatory mediators released from visceral fat. CDC reported that 30% of Americans are overweight or obese (BMI over 30). What’s the link between lack of sleep and developing an overweight condition? Case Western University research showed that women who sleep less than 7 hours a night were 15% more likely to become overweight; women who had less than 5 hours were 30% more likely to develop obesity. A 2010 JADA article reported that dentists are interested in giving wellness guidance but felt they needed more evidence that losing weight would make for a healthy oral environment. If you are reading current periodicals the evidence is arriving.
  9. Sleep is a critical time enabling the body to heal, repair, restore, and regenerate itself reports Mary O’Brien MD author of The Healing Power of Sleep. Next time when giving post op instructions after an extraction or periodontal surgery tell your patient to get 7-9 hours sleep for the next week for optimal healing and recovery.
  10. Alcohol is the most common drug people use to get to sleep. Admittedly it does get you to sleep quickly. Downside, your sleep is lighter – you don’t get enough of the DEEP SLEEP where your pituitary gland releases growth hormone (the youth hormone for fat burning and maintaining muscle mass). With a single glass of wine before bed it spikes your insulin which also takes you out of fat burning mode. Alcohol before bed encourages snoring and sleep experts report even snoring reduces valuable oxygen flow to your brain
  11. As dentists we are aware of the link between inflammation in the mouth and a diabetic condition. Did you realize that poor sleep disrupts may disrupts good blood sugar management?  Four nights of shift work has been shown in scientific studies to bring about pre-diabetic blood glucose levels in those workers during their shifts.  If someone is not responding favorably to your soft tissue management therapy, you need to question those patients about their sleeping habits.
  12. Contrary to belief older people still require 8 hours sleep if they want to age gracefully. Sleep architecture changes with age (they spend less time in DEEP SLEEP and more time in LIGHT SLEEP) and with slower wound healing people over 60 needquality shut eye.

RECOMMENDATONS:

  1. Sleep in a cool (65-68F) bedroom for deeper sleep
  2. Create a pitch black environment so your melatonin levels remain high during the night
  3. Don’t eat before bed as it subtracts from the rejuvenating role sleep plays as your body is trying to digest a meal that should have been eaten at supper time
  4. If you have to cross multiple time zones and want to perform well in business or a sporting event, give yourself an extra day for each hour off your regular time zone.
  5. Sleep scientists say if you are going to workout 4-7pm is the ideal time in terms of supporting muscle adaptation and also to take advantage of the post exercise body temperature adaptation that sets the mood for sleep in the following 3-4 hours. Early AM workouts is still very productive  and they are the best strategy  to make time for exercise in a busy life. It’s just that current research by Michael Howard PhD has shown that late afternoon evening exercise sets the tone for a healthy sleep later that night
  6. “If you are not sleeping well it is almost impossible to heal well”  – NATIONAL SLEEP FOUNDATION
  7. Guided visualization and relaxation exercises are two of the best ways to support healthy rejuvenating sleep
  8. A clear conscious and a peaceful mind make for a short “sleep latency” (the time it takes to get to sleep – ideally 5-15 minutes).
  9. If you want to support healthy REM sleep and utilize its ability to process emotion and consolidate memory, give yourself a mental suggestion right before you sleep to focus on a specific subject or challenge you are currently undergoing
  10. Napping for 20-30min in the mid afternoon has been shown in numerous studies to enhance emotional well-being and productivity. As long as the naps don’t go longer than 30 minutes night time sleep is not impacted
  11. Find the right mattress for your body type. There is no one best type. Studies have shown that medium to firm is most likely to fit most people’s needs
  12. If you get up in the AM earlier than you wanted to, stay up. After a long continuous sleep, expose yourself to bright full spectrum light or sunlight and get your Sleep-Wake routine formalized.
  13. Don’t do anything else in bed except for the two S’s (sleep and _____). Watching TV, doing your taxes, eating  willdistract you from one of the most important health habits you might have. The brain loves cues that it is preparing to sleep. Lugging your laptop onto your lap to answer emails is highly distracting for your night-time brain
  14. Develop a bedtime ritual which cues your brain for slumber. Following the same steps before bed gets your brain ready for zzzzz.
  15. Many over the counter sleep aids are meant only for short term challenges with sleep. Prescription meds work wonders but they too have a number of side effects and many are not designed for long term use. There are herbal supplements but they too pale in comparison to learning relaxation techniques and developing good sleep hygiene rituals (evening/ pre-night time sleep habits).

This subject is new for the dental industry and I hope to share with you further information in the future. In the meantime “sleep well tonight and don’t let the bed bugs bite.”

REFERENCES:

  • Wamsley&Stickgold, Current Biology, 2010, 20(23)
  • National Sleep Foundation
  • CDC
  • Obesity and Periodntal Health: What’s the link? Should I be concernded? W. Ward et al. OralHealth October 2012
  • Sleep and Your Memory by Michael Howard PhD © 2010 Biomed
  • The Healing Power of Sleep by Mary O’Brien MD Biomed © 2012
  • “Dentists Attitudes About Their Role in Addressing Obesity in Patients” Curran et al.  JADA 2010
  • Geyer, Talachi& Carney, Introduction to Sleep and Polysomnography, 2005

 

OdiatuDr Uche Phillip Odiatu BA, DMD is the author of The Miracle of Health and Fit for the LOVE of IT! This busy practicing dentist is also a NSCA Certified Personal Trainer and a professional member of the American College of Sports Medicine (ACSM). He lectures at most of the major dental conferences in the USA, Canada, the Caribbean and England.www.fitdentist.com

 

Dental x-rays: What’s in Your Dose

June 2nd, 2014

By Dr. Dale Miles, BA, DDS, MS, FRCD (C), Diplomate American Board of Oral Maxillofacial Radiology

Doctor with xray

It doesn’t matter whether it’s a periapical, bitewing a panoramic or even a cone beam CT x-ray examination, our patients always seem to be questioning us as to the need for the x-ray. There isn’t a week, possibly even a day, that goes by the dental practice where a dental assistant, dental hygienist her dentist doesn’t hear the following question from the patient, “Why do I need these x-rays?”. And, unfortunately our answers are usually “all over the map”.

“Don’t worry Mr. Jones it’s just like spending one hour in the sunshine.” Don’t worry about Johnny Mrs. Smith it’s like flying across the country in an airplane.” Obviously somewhere at sometime the dentist or auxiliary has been told, heard in the lecture 10 years ago or read in the magazine a comparison made for dental x-rays to everyday activities. Patients are now becoming more sophisticated and actually are demanding real answers and real information to their questions. It is not appropriate to offer them a platitude without any data. It just isn’t that professional. And it doesn’t instill confidence.

The data is out there, and it’s somewhat easy to find. But searching for it really isn’t high on the list of tasks for most of us. In addition, talking about “milliesieverts” is just as foreign to many dentists and auxiliaries as it is to their patients. There is real data about the approximate dose for each x-ray modality, from periapical to cone beam imaging. You can find studies that look at receptor types with round versus rectangular collimation, studies that compare the dose from a panoramic to a certain number of periapicals and x-ray dose even between the various cone beam machines. However, with the myriad of factors that affect x-ray dose, from something as simple as our KV or MAs settings, or the fact that not all cone machines have the same size FOV (field of view), the dose data can be confusing.

So how do we answer our patients question. To date, the best data, or at least the best way that I found for you to use to talk to your patients about x-ray dose actually compares the risk equivalents of dying from everyday activities to the dental x-ray procedure we call on FMS (full mouth series).  Of course even this data comes from comparisons to a full mouth series of film-based radiographs. However, there are still 55% of us out there dental practice using film, despite the fact that faster receptors are available which also will reduce patient x-ray dose.

So, if this initial blog on x-ray dose doesn’t stimulate conversation, nothing will in the dental profession. You need to seek out good data, use something called selection criteria when determining the need for an x-ray exam and transition to the fastest receptors possible and rectangular collimation, which is now been made simple, in order to protect your patient in the best manner possible. Are you up to the task?

Time now to start peppering me with the questions which I’m sure will arise from this initial blog posting. I look forward to your comments and questions. BTW, this is the first time that I’ve accepted an invitation to “blog”. My time, like yours, has become my most precious commodity. But I’m willing to help you find the answers you seek.

 

Miles

Dr. Miles is a diplomate of the American Board of Oral and Maxillofacial Radiology and the American Board of Oral Medicine. He has authored over 130 peer-reviewed articles and 6 textbooks, including the best selling atlas on Cone Beam CT, Color Atlas of Cone Beam CT for Dental Applications published by Quintessence Publishing. Dr. Miles is in full-time practice of Oral and Maxillofacial Radiology in Fountain Hills, Arizona. He is the President and CEO of Cone Beam Radiographic Services, LLC., a CBCT reporting service for dentists and dental specialists and President of EasyRiter, LLC, which produces a simple CBCT report generating software for the profession.

 

 

The Perfect Board Patient

May 5th, 2014

By Paul A. Levi, Jr., D.M.D.

friendly doctor and pacient

Recently, in the predoctoral clinic at Tufts University School of Dental Medicine, the students were preparing to take the Northeast Regional Board examination. A student excitedly came to me and said, “Please evaluate my patient for the periodontal part of the NERB examination. I believe that she is perfect.” The patient must have 12 surfaces of very discernible subgingival calculus and at least two pockets deeper than 4mm. As we were walking to the operatory, the student further remarked that one year ago four quadrants of scaling and root planing had been completed for this patient. I remarked that, should this patient qualify as a Board patient, we as dentists have failed. The student appeared to be shocked at this remark.

Unfortunately, on examining the patient, she qualified. Somehow we did not motivate this patient sufficiently to take care of herself, and although we provided the patient a service of calculus removal last year, we did not provide the service of health. The patient explained that since the student said, “I completed the scaling,” her periodontal treatment was completed, and now she could get her fillings done and her dental therapy would be finished.

I discussed with my student that the procedure of scaling and root planing is not just the mechanical act of taking calculus off of the teeth and smoothing roots, but is educating the patient to understand that it is her responsibility to remove the plaque/biofilm thoroughly on a daily basis. Since biofilm is invisible to the patient they must concentrate on their techniques and be seen for professional hygiene at regular intervals consistent with their needs.

The student then asked, “How frequently should a patient be seen for hygiene maintenance therapy? The sacred cow of dentistry is every six months. This began many years ago when it was said that it takes six months to develop caries, and thus we should see our patients to prevent the caries from becoming large and significantly compromising the tooth. Prevention today, especially with fluoride and sealants does not mean preventing the caries from becoming too deep. It means preventing caries from initiating and preventing periodontal diseases including gingivitis. The latter taking only a few days to occur.1

I suggested that in determining a hygiene interval for our patients, we look at the hygiene status at the time of the maintenance appointment as well as their susceptibility to dental caries and/or periodontal diseases. A hygiene maintenance interval of six months is appropriate for patients with no caries experience and no gingival/periodontal diseases; however, those who present with susceptibility and presently excellent plaque control would do best on a four month interval rather than six months shortening the interval by two months. As humans our lives change and other concerns can affect our routines, thus we may change our hygiene thoroughness. If seen that one time more during the year, we are likely to intervene before dental disease occurs and truly be preventive.

 

1. Loe, Harold, Else Theilade, and S. Borglum Jensen. “Experimental Gingivitis in Man.” Journal of Periodontology. 36.3 (1965): 177-187. Web. 24 Feb. 2012

 

Levi

Dr. Levi was born and raised in Newton, MA. He attended Hebron Academy, then St. Lawrence University, where he decided to study dentistry after graduating from SLU.  He attended dental school at Tufts University School of Dental Medicine after which he accepted a residency in general dentistry in Burlington, VT.  He joined the Navy as a dental officer and served in Great Lakes, IL for two years.  Following that he earned a certificate in Periodontics from Tufts School of Dental Medicine after which he and his family moved to Burlington, VT to open his practice in Periodontics in 1971.  Among the many positions that he has held are Treasurer of VT State Dental Society, AAP Board of Periodontics, AAP Board of Dental Examiners and is now an officer as well as an examiner, and president of the AAP Foundation.  He has taught at the UVM School of Dental Hygiene and is presently on the faculties of Harvard University and Tufts School of Dental Medicine  and Universidad International de Catalunya.

 

Staying Fit on the Road

April 8th, 2014

By Dr. Uche Odiatu, B.A., DMD, NSCA Certified Personal Trainer

woman deciding whether to eat apple or chocolate

Travel, whether it is for business or pleasure, does not necessarily mean throwing all of your hard work in the gym out the window. There are proactive steps that will ensure your trip takes you closer towards your health and fitness goals rather than farther away.

“Twenty years from now you will be more disappointed by the things that you didn’t do than by the things you did. So throw off the bowlines. Sail away from the safe harbour. Catch the trade winds in your sail.  Explore, dream, discover.”

~Mark Twain

  • Affirm to yourself the importance of staying true to your nutritional goals before you leave. Remind yourself of the hard work and effort you have put into your training. Decide ahead if and when you will allow yourself to have a treat night. This will give you peace of mind and the strength to say no to the free airplane cookies.
  • Call the hotel and find out if they have coffee makers in the room. This will be very new for you. You can use this to prepare hot water for instant oatmeal, which you can easily bring in a Tupperware container (bring your own electric kettle if there is no coffee maker). Pack a plastic bowl and a spoon for easy in-room dining. This will save you time and money in the morning. Mix in some tasty chocolate whey protein powder and/or nuts for a great start to your day!
  • Call ahead and pre-order your airplane meals at the time of booking. You can request meals that are low in fat, kosher, vegetarian, or sodium-free to name a few. The bonus about special ordering is that you are often served before everyone else.
  • Pack healthy snacks in your carry-on luggage. Vegetables, fruit, rice whole wheat pitas, nuts, protein bars, and meal replacement shakes will come in handy if you are delayed. Don’t forget your “shaker bottle” for the protein shakes!
  • Drink plenty of water before you leave and remember to stay hydrated during the trip. A well-hydrated body is less prone to jet lag, headaches, and water retention. Avoid alcohol and coffee on the plane as they both can dehydrate you.
  • Don’t let boredom tempt your taste buds into mindless eating. Bring your laptop, a book, a journal, or a copy of your favourite dental or fitness magazine to keep you occupied. Did you know there are many inspirational books available for your Kindle or Kobo?
  • Hit the grocery store as soon as you arrive at your destination. Stock up on non-perishable food items for your hotel room. Excellent choices are bagels, apples, rice cakes, bananas, nuts, rye bread, tuna, and salmon (buy the cans with the pull-off lids if you forgot a can opener). This idea will save you from the late night “hotel vending- machine munchies”.
  • If you are travelling with people who have free license to eat and drink, ask for their support before you leave. Sharing your goals will get them on your side and will save you from the teasing as you reach for your filtered water and your fifth can of wild salmon or Greek yogurt.
  • Maintain your discipline at restaurants by asking for special food preparations. Ask for grilled or broiled meat, sauces and dressings on the side, egg white only omelettes, and steamed vegetables. Everyone will admire your willpower.
  • Make sure you are well rested on your trip. It is easy to make poor food choices when you are lacking energy. Like Vince Lombardi (famous football coach) said: “Fatigue makes cowards of us all.”

There is more to travelling than wining and dining. Remember to have FUN and to create some lasting memories of your trip. Instead of focussing on food, try different activities, meet new people, and enjoy your surroundings. By keeping your self promises you will increase your focus and strengthen your commitment to your personal health goals. Everyone will be amazed and surprised when you return from your trip in better condition than when you left!

 

OdiatuDr U.Odiatu DMD is the author of The Miracle of Health and Fit for the LOVE of It! This busy dentist is also an NSCA Certified Personal Trainer and a professional member of the American College of Sports  Medicine. Www.fitdentist.com

Forensic Odontology

March 3rd, 2014

By Dr. Rick Cardoza

cardoza 4

The field of forensic odontology is that area of dentistry concerned with the application of law in both criminal and civil proceedings. There are two disciplines within forensic odontology, postmortem identification and bite mark (pattern injury) analysis.  Forensic odontologists also assist authorities with multiple fatality incidents, age determination based on tooth development, recognition of child abuse/intimate partner violence (IPV) and participate in civil proceedings as an expert witness.                                                    

    

Dental Identification

As forensic dental identification specialists, we are typically the last conventional option for postmortem identification.  DNA is also now utilized but due to its high cost and the extensive time required for analysis, it is used sparingly or when absolutely no other option exists. Other forms of postmortem identification include visual, personal effects, fingerprints, scars, marks, tattoos, and medical radiographs.

cardoza 1

Forensic dental identification has been successful because of the nature of the human dentition.  The enamel is the hardest substance in the body and the only exposed portion of the skeletal system (fig. 1, 2).  Teeth are very resistant to thermal damage, blunt force trauma, and the dentition remains stable during tissue decomposition.  In addition, the dentition is unique to a specific individual.  This includes not only the morphology of the coronal portion of the tooth but the morphology of the roots, pulpal chamber, and their relationship to their surrounding structures (i.e. sinus proximity, mandibular canal proximity, interproximal bony trabecular patterns etc.).  Following the natural dentition, if you add man made dental restorations, the unique combination for any given individual can factor into the millions.

There are numerous important reasons for identifying the deceased.  A legal certification of death is necessary to consummate legal matters such as life insurance, wills, etc.  There are family and personal reasons as well (closure).  In criminal investigations, it is important to establish the identity of the victim in order to proceed with the criminal investigation and to identify the suspect.  In a fire for instance, the bodies are often burned beyond visual recognition (fig. 3).  Personal effects are also destroyed or lost in the fire. Even if the personal effects are recovered they may not be considered reliable due to the typical calamity which surrounds a fire.  A forensic anthropologist will examine the remains of the skeletal system and can then determine age, race and sex of the victim.  Positive identification is best performed by examination of the surviving dentition by the forensic odontologist.  In a fire where the temperatures may be very high (1000°C) even the dental remains may be destroyed.  Crowns may fracture or explode leaving only the roots.  The bone may also be completely consumed leaving only scattered roots with no bony sockets for reference.

cardoza 2 

Forensic dental identification is most often accomplished by the comparison of the radiographs of the teeth of the decedent (postmortem) with the dental radiographs obtained from the dentist of the suspected victim (antemortem) (fig. 4, 5).  Ideally the antemortem radiographs furnished should be the original full mouth series.  Often this is not the case.  Children’s radiographs are typically bitewings only unless they have orthodontic records as well.  Often times duplicate radiographs, not the originals, are sent and have been either poorly duplicated and/or are not labeled right and left for orientation.  In addition, the antemortem radiographic image may be of poor quality due to improper operator technique (cone cuts, overlapping interproximals, elongation/foreshortening, etc.) or poor processing (contrast, burned images, etc.).  When poor antemortem radiographs are compared to an ideal postmortem radiograph, the two may not appear consistent. This could seriously hamper the identification effort.

In forensic dental identification, we stress that good quality, properly mounted and labeled original antemortem radiographs be sent for comparison.  In addition, copies of the victim’s dental treatment progress notes should be submitted as well.  This allows the forensic dentist to verify dental treatment that was performed subsequent to the date of the radiographs.

It is important as practicing dentists to keep complete patient records on file and continually update them, including the radiographs.  One of your records may be needed for the purpose of a postmortem dental identification.

Bite Mark Analysis

cardoza 5

The study of bite marks involves the analysis of teeth contacting another object or medium. Thus, bite mark analysis is a type of forensic pattern analysis similar to tool mark analysis.  Unlike dental identification which is a quantitative analysis, bite mark analysis relies on the odontologist’s interpretation of the pattern therefore bite mark analysis is primarily subjective in nature.  It is for this reason that bite mark opinions, though based on scientific methods and principles, can be highly variable based on the individual’s interpretation of the pattern injury resulting in experts often giving different levels of opinion on the same pattern injury.  The consequence we see today is that bite mark analysis has become highly controversial and in the United States there have been twenty four exonerations by DNA testing of individuals after they had been previously charged or convicted where the charges/convictions were based partially on faulty bite mark evidence.

The study of bite mark analysis involves the comparison of the pattern injury or bite mark to the suspect biters dentition.  The classic appearance of a bite mark is two semicircular or ovoid arches that oppose each other with a central ecchymosis (fig. 6).  The bite mark pattern is photographed from multiple angles with a scale present for reference.  In addition, the bite mark is swabbed for possible suspect DNA.  On the biter it is necessary to take full arch dental impressions of both the maxillary and mandibular arches.  In addition, complete dental charting of all the present, missing, and restored teeth including charting anomalies such as fractures, spaces, rotations, etc., wax bites, and intraoral photography.  If the accused suspect biter is in jail then collection of these records will require a court order and the individual has the right to have his attorney present (note: the biter could also be the victim who bit their attacker in self-defense).

cardoza 3

Once all the records are collected on the bite mark and the suspect biter then the odontologist can complete his analysis.  The analysis consists of a comparison of the bite mark photo which has been digitally resized to life size 1:1 proportions to an overlay of the incisal/occlusal edges of the suspect biters teeth.  This is accomplished by creating a digital hollow volume overlay of the dental models by scanning the models, using a flatbed scanner, into the computer (fig 7).  Then with the use of photographic software the incisal edge overlay can be inverted and superimposed onto the bite mark pattern photo for comparison and analysis (fig 8).

Finally, the odontologist will submit his report to the entity that retained him.  In this report the odontologist will list all the steps he took to complete the analysis and formulate an opinion.  The range of opinions include: The Biter (absolute), Probable (more likely than not), Possible (cannot be excluded from suspect biter population), Exclusion (did not make the bite), and Inconclusive (not enough data or poor quality data to formulate an opinion).

In summary, forensic odontology is an exciting field where dental health care professionals can utilize their skill and training in dentistry for a field complete outside of dentistry.  Choosing a career path as a forensic odontologist or forensic dental autopsy technician (the auxiliary’s role in forensic dentistry) should not be viewed as a hobby but in fact a second career in addition to your primary career in the field of dentistry.  The hours can be long and the monetary return low or even non-existent but the personal reward and satisfaction can be great.

 

Cardoza

Dr. Cardoza is a forensic dental consultant for the County of San Diego Office of the Medical Examiner, County of Imperial Office of the Coroner, State of California Department of Justice and is the Director of the California Dental Identification Team (CalDIT).  Dr. Cardoza graduated from Northwestern Dental School in 1985 and maintains a general dental practice in El Cajon, California. Dr. Cardoza is a Fellow of the American Academy of Forensic Sciences and is a Diplomate of the American Board of Forensic Odontology.

 

Oral Cancer – A Patients Perspective

February 4th, 2014

By Eva Grayzel

Eva Grayzel, a professional interactive performance artist, was diagnosed with late-stage oral cancer at age 33 and told she had a 15 percent chance of survival. A non-smoker, she was bounced among dental professionals while the ulcer on her tongue grew more prominent and painful. “It was two years and nine months from my first appointment with a dental professional until the day I was finally diagnosed with stage IV squamous cell carcinoma of the lateral tongue. During that time, no one EVER mentioned the words ‘oral cancer’ as a possible cause. Finally, I made an appointment with Dr. Mark Urken, the chief of head and neck surgery at Beth Israel Medical Center. I took the bus into Manhattan that fateful day of April 1, 1998 not having the slightest idea that what was on my tongue was remotely serious, and received the cruelest April Fool’s joke of my life.”

Eva

Eva endured a partial tongue reconstruction, a modified radical neck dissection and a maximum dose of radiation therapy. Through an extraordinarily successful treatment plan, Eva not only survived but also regained her ability to speak clearly. With a second chance at life, Eva couldn’t let the same thing happen to someone else. A champion for early detection, Eva founded Six-Step Screening™, an oral cancer awareness campaign for dental professionals and the general public. For her initiative, she was recognized by the American Academy of Oral Medicine and awarded honorary membership.

Eva2

After speaking at the 2003 ADA Annual session, Eva realized the impact she could have on saving lives by sharing her personal story. The audience doesn’t just hear her story, they ‘experience’ it, as they travel the journey with Eva from a delayed diagnosis of late-stage oral cancer, through the surgery and treatment. When dental professionals hear Eva’s presentation they say, “I never want what happened to Eva to happen to any of my patients.” Because of the personal nature of her story, and the fact that someone such as themselves could have prevented it, motivates them to change how they practice. In contrast to the clinical perspective at educational conferences, Eva humanizes oral cancer, inspiring the audience both professionally and personally. “I share my personal story hoping it will inspire dental professionals to perform oral cancer screenings on all their patients, as well as demand them for themselves and for those they love. Together, we can save lives. It’s more than my mission to educate. It’s my tribute to all those that came before me and my obligation to those that will follow. By publicly sharing my personal journey to help others, I’m gaining back all the years and more of life that oral cancer took from me.”

 

GrayzelMs. Grayzel a nationally recognized Master Storyteller was diagnosed at age 33 with stage IV oral cancer and given a 15% chance of survival. After regaining her deep vibrant voice, Ms. Grayzel applied her stage skills to communicate the depth of her experience in a unique and powerful way. A champion for early detection, Eva founded the Six-Step Screening™ oral cancer awareness campaign for which she was recognized by the American Academy of Oral Medicine. Ms. Grayzel is the author of two children’s books, ‘Mr. C Plays Hide & Seek’ and ‘Mr. C the Globetrotter,’ in the Talk4Hope Family Book Series.

Teeth Healthy Snacks for Kids

January 6th, 2014

By Dr. Andrea Beltzer

Happy carrot chomping girl

Feeding my kids isn’t always easy.  As parents, we are constantly bombarded with information about what is healthy and what is potentially harmful for our children’s little bodies.  As a parent, I take these decisions very seriously knowing that the choices I make for my kids now will likely impact the choices they will make for themselves when they are older.

I have two children, Lucy who is five and Charlie who is two.  They couldn’t be more different in their eating preferences and habits.  Lucy has a major sweet tooth.  We were recently at her friend’s birthday party at OaksPark.  There were lots of treats being served, including lemonade, fruit punch, cotton candy, chocolate cupcakes, and cups of ice cream.  The kids were sitting at a long picnic table, and the adults were chatting at another table.  It was crowded, and I wasn’t really keeping a close eye on what Lucy was choosing to eat at the other table.  As the kids’ table emptied out, Lucy was still sitting there finishing her chocolate cupcake after having a cup of lemonade, most of her cotton candy and the cup of ice cream.  Most of the other kids had abandoned their treats half-eaten, but not Lucy.  This was her chance, and she was going to consume as much sugar as possible in one sitting, since I wasn’t right there to monitor what she was eating.  I went over to her, and we had a little conversation about making good choices, and how eating all of those treats so quickly was probably going to make her feel a little sick later on.   Then I proceeded to try to wipe off all of the gooey chocolate and sticky cotton candy that was all over her face and hands and have her drink a cup of water to try and neutralize some of the acid that was being produced by those sugar-loving bacteria in her mouth.  Some of the parents who were standing around us chuckled with me knowing that I am a pediatric dentist, and it’s my kid who is the last one sitting at that picnic table trying to devour every last gram of sugar that she can.  Parenting fail?  No, not really.  I was more amused by the situation than embarrassed.  I know that what really matters in the long run is the every day choices that we make, not the very occasional big treat that sometimes happens during special occasions and holidays.

Charlie, my two-year old, is the exact opposite of Lucy in many ways, including his eating preferences.  He enjoys something sweet here and there, but will typically have a few licks of a popsicle after dinner in the summertime, and then decide he’d rather get down and play instead of finishing his treat.  My challenge with him is that he’s a grazer.  He is two years old and easily distracted, so unless he is starving, mealtime can take a very long time, and sometimes can result in him not eating much at all.  As a result, he likes to snack or “graze” in between meals.  His top choice of snack would be crackers or chips, and he could graze on chips and crackers all day long if we let him.  We know though that a diet of chips and crackers is not good for his body or his teeth!

Many parents are surprised to learn that even snacks like crackers can contribute to tooth decay.  Any snack that is rich in carbohydrates can lead to tooth decay, even it’s not necessarily considered a “sugary” snack. This is particularly true for kids that tend to graze all day long on carbohydrate-rich snacks, including crackers, chips, cereal bars, fruit snacks, raisins and dried fruits.  Studies have shown that it is not only the quantity of sugar consumed that can lead to decay, but it is also the frequency with which the sugars are consumed.  It is much worse for a child to sip on juice or snack on crackers if they are sipping or snacking over a long period of time, than if they were to have a few ounces of juice with their breakfast.  I’ve alluded to the role that bacteria play in tooth decay.  We all have bacteria in our mouth and some of these bacteria are responsible for contributing to decay.  The bacteria consume the sugars that we consume, and then produce acid which breaks down tooth enamel causing cavities.  If the bacteria are fed all day long by those who graze on carbohydrates throughout the day, they are constantly producing acid, and the mouth remains at an acidic pH for long periods of time which results in tooth decay.  Preventing your children from grazing throughout the day on carbohydrate-rich snacks is important for the health of their teeth.

Limiting juices, flavored milks, and other sweetened beverages, as well as encouraging your children to drink a lot of water in between meals can go a long way to prevent cavities.  Chewy snacks that are high in sugar, such as fruit snacks, raisins and dried fruits should be avoided in general, but especially for children with deep grooves on their molars.  These snacks really stick to teeth and are hard to remove from teeth even with good tooth brushing.

I have discussed a lot of things to avoid, so now I will talk about some of my kids’ favorite “teeth-healthy” snacks.  My kids love avocado, and that makes a great snack all on its own or sliced lengthwise with sliced turkey or ham rolled around it.  If your child is old enough and doesn’t have any nut allergies, nuts are a great snack food too.  My kids love almonds and cashews.  Whole fruits (not dried) and veggies are great.  My kids really started taking more of an interest and were more adventurous with trying different fruits and veggies when we planted a vegetable garden.  They love picking strawberries, cherry tomatoes and yanking carrots from the ground in their own backyard!  Other favorite fruits and veggies in our home are celery sticks with cream cheese, apple slices, Satsuma oranges, and carrot sticks.  Bananas are always a good portable snack when you are on the go.  They are nutritious and filling.  For kids that can tolerate dairy, cheese sticks are another easy “tooth-healthy” snack.  My kids also really love hummus, and almost any veggie tastes good dipped in a little hummus.  Costco sells boxes with individual servings of hummus that are very convenient for snacking.  Olives are popular in my house, not only because you can have fun putting them on your fingers but because they taste good too.  I also try to ask Lucy for ideas when I think she is getting bored with our usual lunches and snacks.  She often sees her friends at school eating things that I would never think to pack for her!  One of her school friends often enjoys red peppers stuffed with tuna salad for her lunch.  I would never think that a 5-year-old would enjoy something like that, but Lucy was interested in that because she saw her friend eating it.  Now she loves red bell beppers!  For some reason, kids always think their friends’ lunches look better than their own, so ask your kids what their friends are eating, and if they are interested in trying some new things!  You might just be surprised at what your kids will eat!

 

090725PTTBBELTZNERA11Dr. Andrea Beltzner received her certificate in Pediatric Dentistry from the University of Connecticut in 2007, and became board-certified in the specialty of Pediatric Dentistry in April 2008.  Along with her husband, adorable children and  two adorable dogs, Dr. Beltzner lives and works in Portland, Oregon. Passionate about helping underserved children receive the dental care they so desperately need, Dr. Beltzner volunteers regularly at Creston Children’s Dental Clinic, on the Tooth Taxi, at the annual Children’s Health Fair along with being a co-lead for the pediatric department at Oregon Mission of Mercy, and a volunteer on the Emanuel craniofacial team.

Dental Emergency First-Aid

December 12th, 2013
By Dr. Weston Heringer, JrTooth First aid

Dental emergencies, especially with children, can happen any time.  Listed below are the most common types of emergencies and what action to take following the emergency.   It is always better to be prepared!

  • TOOTHACHE Clean the area of the affected tooth thoroughly.  Do not place aspirin on gum tissue or aching tooth. If face is swollen, place cold compress to the outside of the cheek.  Contact a Dentist.
  • CUT OR BITTEN TONGUE, LIP OR CHEEK If there is bleeding apply firm but gentle pressure with a clean  cloth or gauze. If swelling is present, apply cold compresses. If bleeding doesn’t stop readily or bite is severe, contact a Dentist.
  • BROKEN TOOTH If center nerve of tooth is exposed or center shows pink color contact a Dentist immediately.  For comfort, the injured area may be covered with a moist warm cloth.  If edge or corner is broken seek care at your convenience.
  • KNOCKED OUT PERMANENT TOOTH   Time is critical, find the tooth.  Quickly rinse the tooth, if possible, and reinsert it in the socket.  Have the patient hold the tooth in place. A tooth that cannot be reinserted should be kept moist.  The patient must see a Dentist immediately.
  • KNOCKED OUT BABY TOOTH  Primary teeth are not reimplanted, if you have questions about the injury, contact a Dentist.
  • BLEEDING AFTER BABY TOOTH FALLS OUT  Have the child bite on a folded gauze placed over the bleeding area for 15 minutes.  If bleeding persists contact a Dentist.
  • BROKEN BRACES AND WIRES  If a broken appliance can be removed easily take it out.  If it cannot ,cut it off.  Cover the sharp or protruding portion with cotton , chewing gum or wax.  Loose or broken appliances do not usually require emergency attention.
  • POSSIBLE FRACTURED JAW If suspected, contact a Dentist immediately or take the  individual to Hospital Emergency Room.
  • COLD/CANKER SORE  Over-the-counter preparations often give relief. Stay away from salty or acidic foods.  If sores persists over two weeks contact a Dentist.

 Editors Note: Please consider this non clinical advice and always consult your dentist with any questions or concerns.

Dr Weston Heringer

Dr. Heringer is a retired pediatric dentist and has served on 19 overseas dental trips. He operated a private practice in Salem for 30 years with a satelite office in Lincoln City for 26 years. For the last two years of his career he was the full time dentists on the Tooth Taxi, a mobile dental van providing free care to children in Oregon. Dr. Heringer is a past president of the Oregon Dental Association and is a board member of the Dental Foundation of Oregon.

 

 

Weight-training…an Anti-Aging Tool?

November 4th, 2013

By Dr. Uche Odiatu, B.A., DMD, NSCA Certified Personal Trainer

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Many dental professionals are strategically mapping out their future financial security. They are tax planning and using the 10% solution to save and invest their hard-earned money. Freedom 55 used to be the catch phrase championed by many financial advisors. But with the recent economic challenges I can easily see it being called Freedom 75. The irony is that most people over fifty do not enjoy excellent health and physical fitness. How can anyone indulge in their monetary abundance without the ability to physically take care of him or herself?

Robin Marantz Henig, Scientific American magazine writer reported that almost half of North Americans over 75 require some assistance with their daily tasks. Unless there are major advancements in senior fitness levels, aging North Americans may spend their latter years in conditions of debilitating dependency.

Dr. Steven Lamm (author of Younger at Last) found that non-active men and women lose one percent of their muscle mass every year after 30. This will result in many consequences in the quality of life: lack of ability to take care of your dream home; inability to enjoy travel; problems with posture; and greater incidence of falls with diminished leg power for balance and movement. Less muscle a (very active tissue) means slower metabolism, which will eventually result in more bodyfat (inactive, useless tissue).

It is downward spiral. The less muscle you have, the fewer calories you burn each day. And the less strength you have the weaker you become. Daily activities like going grocery shopping and climbing stairs become more challenging. Result? You become even less active.

Do these sound like dire consequences? What can you do to stem the tide? Try adding strength-training or weight-training to your weekly activities. That’s right – those dumbbells and barbells in the gym are not just for the bodybuilders on the beach!

Recent research has shown that one of the most important steps in not just retarding the aging process, but in reversing the process, is resistance or strength training. It is not just a suggestion, it is recommended! Studies at Tufts University have shown that people in their 70’s, 80’s and 90’s have benefited from safe and effective strength training in many ways, especially their balance and motor skills.

Can resistance training help you fight chronic illness? New research by the American College of Sports Medicine has shown that a simple 12 week resistance training program decreases inflammation (a key player in every chronic disease) in the body. In Medicine & Science in Sports and Exercise Journal November 2012 a study showed that after just three months of a moderate intense weight training program circulating C Reactive Protein (CRP) decreased 33%, leptin 18%, and TNF (tumor necrosis factor) by 29%. Don’t those numbers get your workout juices flowing? If not now…when?

Sadly, only 10% of all regular exercisers include any strength training programs. The types of exercise they choose for the most part are aerobic in nature: walking, running, cycling and dance classes. These are excellent activities for maintaining cardiovascular health and fitness, but they do not contribute in a significant way toward maintaining or building muscle mass. The best exercise program combines aerobic activity, flexibility and strength-training exercises.

Why not include physical fitness to ensure your enjoyment of the golden years? Seek out a certified personal trainer or join a strength class at your local health club. Remember, always check with your health care provider before starting any new exercise program.

See you at the gym.

 

OdiatuDr U.Odiatu DMD is the author of The Miracle of Health and an NSCA Certified Personal Trainer. This busy dentist is also a professional member of the American College of Sports Medicine. He lectures at the largest dental conferences in North America. www.fitdentist.com