Episode 185 – Requested Replay: Getting to the Root of the Issue
“We need to fix the root of the problem. Otherwise we’re just mechanics replacing a part that will continue to go wrong.” ~Dr. Bruce B. Baird
A lot of patients walk into your office frustrated before they even meet you. It’s not you, it’s dentists in general and why wouldn’t they be frustrated? Dentists keep fixing things in their mouths and the fixes keep breaking down.
This is where I think we’ve made a mistake in dentistry. As a profession, we fix the problem, but don’t educate patients about the underlying cause or long-term solutions but I believe our patients deserve more and if you’re listening to this podcast, you believe that, too.
When I check for decay in a patients mouth, I also checking for acidity or erosion. These are things that can absolutely destroy a person’s dentition and, if the patient doesn’t understand what they are doing to cause more decay, then any work you do for them likely won’t last.
The bottom line is long-term health for these folks is not a reality if we don’t address their risk factors and help them see what is causing the decay and what they can do to help prevent it.
And I repeat, your patient’s risk factors are not your fault but there are ways you can ensure your work lasts and your patients have the information they need to make healthier choices. Join me today as I talk through how I:
- Look for the underlying causes of erosion
- Share information so patients understand the causes of their risk factors
- Remember what is the patient’s responsibility and what is my responsibility
Dr. Bruce Baird
Hey, this is Dr. Bruce Baird, this is our Productive Dentist Podcast, we’ve been talking a lot about risk factors over you know, over the last few weeks, and today we’re going to talk about biomechanical risk and these come from John Kois’ risk factors and I’ve added a few at the end of these, he has four and I added a couple of additional ones we’ll be talking about over the next few podcasts but when we start talking about biomechanical risk, it’s more than just decay. I mean, I think a lot of us think of biomechanical risk being, you know, we always check first for perio, then we check for decay. Well, I check for not just decay, but also I look for acidity or erosion. You know, the class fives that you see that eroded or the incisal edges of posteriors that are eroded. You know, some of that it’s, it’s not really a decay problem at that point but it is definitely an acidity problem and those are things that can absolutely destroy someone’s dentition. I’ll even see it at times in teenagers and in early adults, where they’re getting this erosion in the posterior. What are some of the things that can cause erosion? You know, what are the things that I’m thinking about? When I see in the mouth, signs of erosion decay is a different topic we’ll talk about both today but when I see erosion in an adult, male, late 40s, or female in her 50s, I started seeing erosion, I started thinking about sleep apnea, because you know, during when they stopped breathing, and all of a sudden, they’ll gasping for air, and in many cases, you’ll get reflux.
So you’ll get acidity. I also think in some individuals, usually, it’s females, teens, early, or early adults, you’ll see signs of bulimia, where the lingual is of the uppers and in some posterior is have got this erosion. I’ve also seen erosion on being down in Texas, you know, we see people, Hispanics that have grown up chewing on lemons. So you know, you go don’t do that, you know, let’s quit chewing on the lemons. So there and when you’re talking about risk factors, remember, I’m giving them this information before I really even do their full treatment plan because I want them to understand the cause behind what’s going on. Another thing that can cause erosion and cause decay problems is obviously medications. Almost every single medication that patients are taking today, whether it be thyroid meds, whether it be antidepressants, anti-anxiety, medications, cholesterol, blood pressure, you kind of go down through the list, and they all cause dry mouth and, you know, as medicine in the US has been taken over by the pharmaceutical companies. If there’s a pill for something, you’re gonna get it and it almost always drys the mouth out and so when I start seeing decay on anyone in areas where and choose a middle age to, you know, older patients, but I will see new decay in areas where there’s never been decay before and I tell my patients, oftentimes I’ll say, “You know, you, you go through two times in your life where you’re decay prone,”and I only say this if that patient has had a history of having a bunch of decay, because what we know is some of us as kids are infected with bacteria that are very high acid producing bacteria and others aren’t, you know, we’re not infected with those bacteria and the people who are infected, you look at a Dr Pepper or a Mountain Dew and you get to k, the ones who don’t they drink Dr. Pepper and don’t ever get a cavity and I tell my patients, “You know, it’s not fair, it’s just the way it is,” and so what we’re going to have to do is with those folks is we’re going to put them on a certain regimen to try to help them because the long term for these folks is very poor, if we don’t handle these, these risk factors, and so have been on medications can also cause that erosion that you see, because it may not even be decay, but they’re getting getting erosion, which is, again, detrimental to your dental work. With the decay part of this, anytime we start seeing that decay in those areas that have never had it, I tell them, they’re high risk and we’re at a while on the road, many of these patients have had a lot of dentistry over their career over their lifetime and they’re frustrated. They’re frustrated with us as dentists because we keep fixing things and it keeps breaking down. They talk about their last dentists or the dentists before, “I had a filling I had this done and it didn’t work,” and what I would love to see happen across the US and across the world, is that before any dental work is done on any patient, you go through their risk factors because these risk factors are critical towards long term success.
If we don’t do that, then truthfully, in my opinion, we’re not really helping the patient, we’ve just become a mechanic and the car comes in and we got to change spark plugs but you know, maybe the spark plugs have been changed five times in the last year, but nobody really cares what’s causing that. Well, that’s what I feel like in dentistry, I think we’ve let our patients down in many instances where we just fix teeth when they come in and I talk to my patients and you know, a lot of the verbal skills that I use, I’ve been using for years, and then I always come up with new things but one of the things I tell folks is, “You know, as you’re,” you know, for instance, a lower anteriors people think, “Well, my lower interiors are wearing, what do I do you know, they’re wearing down?” Well, part of that is a functional risk. So I’m not talking about the erosion but once they ground through the enamel of those lower interiors, you start to see that dipping are that cupping on those interiors, uppers and lowers and I tell patients, you know, it’s kind of like, if you took an m&m and turned it on its side and you started shaving it, you’d have this hard outside and a soft inside and the American diet being very acidic and you, in particular, having a lot of acidity issues with medications and other things, you notice this real dipping, I can do restorations in that, and these are white colored restorations that I put on the incisal edge of your teeth, or on these, this little area and I show it to him, and I said and it’s acid resistant, and it will help that to stop eroding in that area and so that’s something that, you know, one of the verbal skills I use with those patients. The others, you know, when I see patients that you know, have the super dry mouth and we start talking about, “How can I help you long term?” Well, that is worth carrying free rinses carry free wrenches I love not only from a periodontal standpoint, which is not really talked about. they’re there but also from a neutralizing the saliva in the mouth and I’ve talked to Kim coach before and Kim said, “If they’re using that risk for two years, two and a half, three years, what happens is those high acidic bacteria that are have been in their mouth over the years, now starts to go away because they don’t like living in a non-acidic environment.” They like acid and so that’s the deal and if I tell my patients that I said, “You know, we’ve got rinses now, it’s not all about fluoride,” which may surprise some of you because everybody’s like, “Oh, give them fluoride here, give me fluoride there,” but we all have had patients that we give fluoride to give fluoride appliances to so they wear him every day and they still keep getting to decay. Well, the only way to get to decay is acid, you know, as the acid that is being produced, and we got to get rid of that.
Otherwise, the dentistry that we do is just simply not going to last. From the other things when I look at decay, what kind of restorative materials do we use and where do we put the margins of our crowns? I’ve been following patients now for 38 years and when I can go subgingival on a patient who has a lot of acid risk issues and I can get into that. It’s kind of a buffered zone under the gingiva and has them using rinses to help neutralize acid I’ve seen along term success and long-term results. Now my preference, in many cases is, you know, in most cases is to go super gingival but when I’ve got that patient who’s got to decay throughout the mouth, that’s where, you know, that’s where the issues really happen and, you know, I just don’t want to do their dentistry, it’s not about money. It’s about I want whatever I do for them and I tell this to the patient, “I want whatever I do for you, Mary, I want to last the rest of your life or at least have a chance. Now you could get sick, you could get on chemo, radiation, there are lots of things that can happen but let’s, let’s hope not but what I do know is that if we keep going the way we’ve been going, you’re at a wind erode. Now, you’ve got to make that decision yourself. Where are you headed?” And when I say a windy road, I put my hands like a why and I say, “You go this way, we can actually restore your teeth but let me tell you a few things that you’re going to have to do. You’re gonna have to stop drinking Dr. Pepper, period, and if you don’t think you can quit drinking it,” and I’ve had patients go, “oh, there’s no way I’ll never quit drinking Dr. Pepper.” I said, “Okay, then we really have to eliminate this direction and we have to go this direction.” “And what is that direction?” “Well, that’s taking your teeth out.” You know, most of these folks have already lost 5, 6, 8, 10 teeth, and they want you to fix their teeth. I don’t want dentures. “Well, okay, you don’t want dentures, but you don’t want to quit drinking Dr. Pepper,” and remember what I say, PDA for those of you who’ve been through productive dentists, I say, You know what, what’s really cool about this, what’s really neat, it’s not my problem.
You know, I for, gosh, 30 years, I took responsibility for everything, you know, if, if, if, if they got decay on a margin of a crown idea, that must have been the margin that wasn’t good. You know, it must have been my dentistry that wasn’t good enough. in dental school, you know, everything had to be perfect. Oh, you get an A if the, if it’s perfect and, you know, if the marginal Ridge is not perfect, you get a C and so you’re always thinking about perfection and so we tend to want to take responsibility for that but we never asked the patient about their oral about what they’re doing. What kind of drinks do you drink, what kind I had one patient who never had a cavity in their life and he was 82 years old, he would come in once a year and I would check him out and everything was great and I would just say just keep doing what you’re doing. One year, he came in one year later, during the Christmas holidays and the team came in and said you got to see this I looked at his X-rays and I was like, “Oh my gosh.” He had gone he had decay in every tooth in his mouth. Now I wish I would have seen him at the six-month mark, we might have been able to stop up, and literally the decay was so bad. He was gonna have full mouth extractions.
What happened to him that previous year, he had had a heart attack and he got on a bunch of meds, beta-blockers, ACE inhibitors, and he got on a bunch of stuff and his grandkids got him hooked on Werther’s candy. Well, we’re there’s I love Werthers but when you have dry when you can’t spit in a thimble when you have no saliva, and you start sucking on those things all day long, you got problems, you’ve got major problems, you’re gonna get to decay and sure that’s what happened to him. We have another patient who we’ve been seeing I just saw him about a month ago. We have X-rays from 12 months ago, and all of his lower anteriors no decay. He started and he was a dipper in Texas, you have guys that dip Copenhagen? Well, he decided to get off the Copenhagen he started dipping the synthetic stuff. Well, the number one ingredient of this synthetic was molasses. His teeth went from no decay to decay on F, the entire anterior was almost decayed away in literally 12 months. So these are the kinds of things when I’m working with a patient, I want them to feel like I’m on their team but I also want them to know it’s their problem, not mine but I’m here to help them make a decision on whichever way they decide to go. I mean, I do implants. I mean, I’m more than happy to place six implants up top and four or five implants on the bottom and make them a fixed in the mouth permanent, you know, per Taos or Konia hybrid at 60 grand, or I can help you fix your teeth. Either way, it’s not my problem. I have options that can help you but once patients realize don’t tell you usually, “Nope. I’m never going to quit drinking Dr. Pepper so well.” Okay, that’s no prob, and last, what if they say, Well, I just want to fix this front tooth right now. I’ll fix it. I’ll say well, let’s put it put a crown on it. Let’s do something. I’ve done build-ups and tried to help people restoratively like that for my whole career and I said, “No worries and I’m just going to make a note of all the stuff we talked about.”
So the patient really understands, I don’t know how this is how long this is going to last. Talking about those kinds of things with erosion and with decay, it can be devastating in the mouth, as we all know, if you’ve seen patients, but what I’m saying is, it’s absolutely important to put the responsibility on the person who it should be put on, and that is the patient. Now, our responsibility is to do fantastic dentistry, you know, do beautiful margins, you know, how many times have you put something in and you looked at it a year later, a year and a half later and in hygiene, they took a bite where you go, “Oh, my gosh, that margins open.” I just read to him, it’s not even an issue for me. That’s why I also have a five-year guarantee on what we do. It’s unwritten, but I just tell people, Hey, you’re with me my five-year guarantee, if I see anything that’s going on, as long as they’re following the rules, as long as they’re coming in for their hygiene, as long as they’re using the carry free rinse. It’s kind of funny when they come in with their carry-free rinse and you ask them if they need some more and they say no, I said, Well, are you using it? Well, yeah, most of the time. Well, that means no, they’re not using it. So remember, Dr. Berry, you’re going to have to pay the full fee.
If this stuff decays, you’re gonna have to pay the full fee because of it. You know, if you know, we’ll talk more about the night guards and all those kinds of things or periodontal risk, even if you’re not coming in for your periodic care, hey, all bets are off, we don’t have a guarantee of five years but I want them to know that I’m on their team and that’s, that’s, to me is what’s most important.
So I hope this kind of a different way of looking at risk, right and we’re, you know, we’ll give you you know, some pause when you’re talking to those patients and our entire exam process, you know, we’re gonna go through that also, and how we do that in the future but I hope this has been helpful for you. It’s a new year, Happy New Year to everybody out there, please go on online and register for our podcast and go to the iTunes accounts and register and we’re going to keep pumping these things out and so I sure hope it’s helpful and let me know, email@example.com If you have questions or something pops up that you really would like me to talk about, let me know and we’ll do that. So look forward to the next one.
Thank you. Thank you for joining me for this episode of the Productive Dentist Podcast. If you found this episode helpful, make sure you subscribe, and pass it along to a friend. Give us a like on iTunes and Spotify or drop me an email at firstname.lastname@example.org don’t forget to check out other podcasts from the Productive Dentist Academy of productivedentistpodcast.com Join me again next week for another episode of the Productive Dentist Podcast