Implant Teeth-in-a-Day: Ms. Smith’s Story

Doctor Kulaga
Here at White Wolf Dental we pride ourselves in patient education and post articles to inform our patient’s about the latest advancements within dentistry. This time we will be doing something different; sharing a story.
 
 
 
 
 

Ms. Smith

A woman in her early 50’s came to our office tired of wearing her partial dentures and not wanting to smile due to the appearance of her teeth. She wanted to have a smile that was not removable, even while in a temporary phase. Below you can see Ms. Smith’s smile with and without her old nylon partial dentures.

Ms. Smith's old nylon denturesMs. Smith's smile with no dentures

 
 

Gum Disease

Ms. Smith has had a history of very aggressive gum disease. Millions of Americans live with gum disease which can be managed, though at this point there is no cure. She had very few remaining teeth, as the photo above shows. Due to a lack of bone support from this aggressive gum disease, fixed bridges would not be an appropriate alternative. When gum disease reaches a very aggressive point, the only option left is extractions. Ms. Smith has family and friends that wear full dentures. She has heard many stories and complaints, particularity with the lower denture which tends to have no stability. She knew implants were an option, but feared that due to the aggressiveness of her gum disease there would not be much bone remaining. Thankfully, technology has improved to allow us to take a 3D scan like the one below and analyze the bone in great detail.

3D scan used to create a digital model for implant design

Teeth-in-a-Day

We began the process of Teeth-in-a-Day by taking the 3D scan and study models. From this information our team of doctors digitally planned the implants to place them into ideal bone. We also modeled her new smile based on this information.

All this planning let Ms. Smith walk in with her old teeth and walk out with a new beautiful, fully functional smile the same day.

Her first set of teeth placed on the day of surgery were her temporary set, but they were screwed into place and non removable. We make our temporaries very robust by adding a metal frame for support and pins in the teeth to lessen the chance of breakage while we wait for the bone and implants to heal for about 6 months. Below is Ms. Smith’s temporary smile and implant planning.

3D digital design used to plan implant placement

Ms Smith's temporary implant dentures

Note that the red spot between the teeth in this photo is not blood, but a bit of wax left over from the process of molding the denture. This wax is not harmful and is easily cleaned off with a toothbrush.

 

 

 

 

 

 

 

 
 
 

Strength & Beauty

After some healing time we began the process of making Ms. Smith her new smile. At White Wolf Dental we do not have the option of plastic teeth over a metal bar, which is the most common type of prosthesis for teeth in a day. Instead we offer two options: the Diamond Hybrid, which was developed right here in our office, or a full Zirconia prosthesis. Our Diamond Hybrid is the same cost as the common plastic teeth, but it has the strength and beauty of porcelain. Below is Ms. Smith final smile. On the delivery day of her definitive prosthesis, she brought in gum to chew; something she missed for many years.

Ms. Smith's final implant dentures

With proper planning, there are options for individuals that have aggressive gum disease or cavities. We offer teeth that can snap on over implants or, similar to Ms. Smith’s, a non-removable option that functions just like natural teeth. You don’t have to wear the kind of dentures your parents might have; you deserve a better smile!

Healthy Eating for Healthy Teeth

Doctor Scarpitti

Recently, at one of my weekly gym sessions, I over heard a client ask a personal trainer for some nutritional advice. Typically I try to avoid eavesdropping on conversations while at the gym, but this time I thought I could gain some insight as to what the new “food for thought” on healthy eating consists of. The response by the trainer was pretty similar to what I was taught as an undergrad. The take-home message was to limit high fat foods, eat plenty of fruits and veggies, and drink plenty of water while consuming smaller, more frequent meals. This is well known in personal training and nutrition to help reduce what are known as post meal time insulin spikes; aka sugar spikes. In short, this aims to help maintain steady blood sugar levels throughout the day to avoid over-eating at meal times and reduce caloric intake. Many nutritionists advocate for this diet and I also agree with the science behind the recommendation. However, an issue arises from a dental perspective when people don’t know exactly what eating more frequently means, nor the type of foods to eat.

Unfortunately, when some one is told to eat smaller more frequent meals per day to help lose weight, most people tend to think they should “snack” on healthy foods. The goal should be to aim at consuming 3-6 small well balanced meals at planned times, instead of grazing or snacking throughout the day. We know that with higher frequency of food intake, particularly sugary foods, there is an increased risk for dental decay. Although one’s intentions to eat more frequently may be good, a lot of time the type of food choices recommended can be harmful to the enamel of teeth.

People are generally aware that consuming a diet high in sugar will cause dental decay. To most, high sugar foods consist of candies, sodas, and foods containing high fructose corn syrup. But did you know that foods such as bananas, dried fruits such as cranberries, raisins or strawberries can be just as detrimental to the tooth surface as those other processed foods? The reason is due to the ability of these foods to adhere or stick to the tooth surface and provide a longer exposure time to the oral cavity which provides a constant food source for the bacteria that cause cavities. Combine this with snacking on such foods over longer periods of time and we have a common recipe for dental decay.

Another consideration is the acidity of foods. Food choices such as low sugar orange juice or other fruit juices seem to be a sensible healthy food option. What most people don’t realize is that these juices are so acidic that they approach the acidity level of battery acid. That acid attack weakens the enamel on the surface of the teeth causing the teeth to be even more vulnerable to bacteria in the mouth that cause tooth decay. Combine this with the natural fructose and added sugar, which provide a food source for the bacteria, and we have an higher possibility for cavity development.

So as a dentist, what do I recommend to balance a healthy diet and prevent dental decay? First and foremost avoid highly acidic, processed, and sugary foods such as fruit juices, sodas, and even diet sodas (which are still highly acidic). If these foods must be eaten, only consume them at meal times and never snack or sip on them over long periods of time. Also, consider washing these foods down with more basic foods such as water, milk or other dairy products that are low in sugar content. Avoid snacking on foods which adhere to the tooth surface like bananas or dried fruits. Fresh fruits and veggies are high in fiber and water content and require longer chewing time which will help clean off the surface of the teeth. This also helps to stimulate salivary flow which is crucial to maintain a more neutral environment in the mouth. Calcium and Phosphorous rich foods such as meats, poultry, fish and eggs will also help to strengthen the tooth surface. Perhaps the most important things to remember are to brush at least twice daily for at least two minutes with fluoridated tooth paste, floss daily to help maintain healthy gum tissue, and drink plenty of water containing fluoride.

More information on what foods are tooth friendly and what foods are not can be found at www.MouthHealthy.org.

-Dr. S.

Periodontics and Health

Doctor Kulaga

Two weeks ago my sons and I watched the post man drop off our Saturday mail. As usual my three and five year old were more than excited to see what the post man delivered. My three year old says “dad, here’s your tooth magazine”. Sure enough it was a journal with a large tooth on the front, but what I saw amazed me. This was not a dental journal but my wife’s journal for Physician Assistants, “The Clinical Advisor”.



The Clinical Advisor – Preventing and Treating Periodontitis

I began to read the article and on page one I read a very powerful statement;

“Primary care providers, including nurse practioners (NPs) and physician assistants (PAs), should become more aware of periodontitis so that they can educate patients about preventive strategies, assess and monitor patients’ oral health, and select appropriate treatment options”.

I say this is powerful because the statement illustrates that primary medical care professionals are realizing the importance of addressing something that has always been largely left to the dental community. These bacteria and disease processes in the mouth affect the entire body and millions of Americans are going untreated for this serious disease.

In the past, having receding gums, bad breath, and shifting teeth were all considered a normal part of aging. We now understand this is not the case, but rather bacteria in the mouth are destroying the bone support around our teeth. Modern medicine is showing us that the affect of this bacteria is not just limited to our mouths and teeth, but affect our entire bodies. As this article illustrates it can be difficult for a patient with diabetes to control their sugar levels that have uncontrolled periodontal disease.

Some other examples; just recently here in our office we had two patients who could not get clearance for medical surgeries, a shoulder replacement and heart surgery, until their oral health was in order. Also, new studies show there maybe a connection with arthritis and periodntal disease. As a dentist it is difficult to translate the importance of controlling periodontal disease as in most instance it is painless. Many patients do not experience pain or discomfort from periodontal disease until it is too late and when it reaches this point, treatment is usually tooth extractions. With modern dental treatment we can avoid this scenario and usually treat periodontal disease with a laser that does not require cutting of the gum.

Here at White Wolf Dental we recognize the importance of battling a disease that impacts about 47% of Americans and most people may not even be aware of. To help in caring for our patients to the highest standard, we invited Dr. Adrian Abrahams to join our team. He is a Periodontist, a dental speicalist with three additional years of training to treat disease of the bone and gum. His skills add an important dimension to our dental team and open up new possibilities for diagnosis and treatment of oral health issues. Not to worry, we haven’t raised our fees because we hired a specialist! If you have any questions, always feel free to ask us.

-Dr. K

Insurance Issues

Insurance can be a confusing subject, and dental insurance is no different. With so many different companies and policies in the market, it can be difficult to know just how your policy works and what it covers. Employers can even have different policies within the same business. Just because you have a policy doesn’t mean your co-worker has the same policy. These are some common misconceptions we’ve seen from patients regarding dental insurance. The following information is not true for all policies but are the most common issues we see among a variety of insurance companies.

• Cleanings are NOT FREE!!! The cost for cleanings does come off your annual maximum benefits.

• If you have had a filling or crown done your insurance will not pay to have the procedure
done again for a specific amount of time. Fillings are a payable benefit 1 time in a 2 year
period. Crown are a payable benefit 1 time in 7-10 years. It does not matter the reason for
needing to be replaced it is never a covered benefit outside these specifics.

• If you are having teeth extracted we usually recommend a healing partial or denture. This is
a prosthetic that is worn until the patient’s tissue is completely healed, usually for 6-9 months. After that healing period, a final difinitive partial or denture is placed. Many insurance policies will only pay for a crown, partial, or denture one time in a period of 7 – 10 years. What this means is that you may not want to bill the insurance company for the healing denture, or they will not pay for the final denture 9 months later.

• Bleaching and Veneers are considered cosmetic and almost never covered.

• Fluoride treatments can sometimes be the most preventive treatments and insurance companies only pay for 1 treatment per year til the age of 15. So not all preventive services are covered at 100%.

• If you have a concern of how much you will be reimbursed we can do a Pre-Determination of
Benefits. We will submit the procedure codes that you to have done and the amount we charge and the insurance company will let us know the amount they will pay. Do not be fooled, THIS IS NOT A GUARANTEE OF BENEFITS!!!

• If you have any questions regarding your policy call the customer service number on the
back of your insurance card to get current and accurate information.

Questions to Ask Your Insurance Company

These are some questions that we recommend everyone with dental insurance ask their insurer. Many details of dental insurance policies can be difficult to find in the technical language of the policy itself, and may not be clearly spelled out in any paperwork. Sometimes, the only way to find out is to ask.

1. What is my calendar maximum for the year?
2. Does my calendar maximum run from January to December, or from my effective date?
3. What is my calendar deductible each year? Individual or family?
4. Is my plan a PPO or DMO?
5. What is my coverage breakdown on preventative, basic, and major services?
6. Do I have a waiting period on basic or major services? If so, how long?
7. What are the time limitations on Panorex x-rays, Full Mouth x-rays, and bitewing x-rays?
8. Can I schedule my cleaning appointment twice a year, or does it have to be 6 months to the day to have this benefit paid?
9. Does my pan have a “missing tooth clause” in effect?
10. What is my group number, mailing address for DENTAL claims, and customer service number?
11. Does my plan cover implants or implant crowns?
12. Does my plan cover sealants for my children? If so, what is the age limit?

In the end, it is up to each of us to become experts in our own insurance coverage and act as our own advocates to maximize the value of the benefits we pay for. Hopefully some of these tips and ideas will help you get the most out of your dental insurance policy.

Osteoporosis and Dentistry

Doctor Valenzi

It is important to be complete when updating us on your health history, even if your medical condition may not seem relevant to dental treatment. One common and important example is osteoporosis.

Osteoporosis is common in our patients, and is often treated to prevent bone fractures, especially hip fractures. This is a serious problem as 20% of women, and 30% of men suffering from osteoporosis won’t survive the event and 75% will not regain full function. Now, osteoporosis (OP) in itself has little effect on dental disease. For example, you are not more likely to have bone loss from gum disease if you have OP. This may seem odd since both diseases involve bone loss, but gum disease involves bacteria and inflammation, while OP has more to do with changes in your bones normal building and remodeling machinery. For dentists, the important point is – are you on drugs to treat the OP?

As first reported in 2002, drugs used to treat OP can cause delayed healing, and serious bone infections. Usually this is after tooth extractions, but could be from something as small as a denture sore spot or be completely spontaneous. The symptoms could range from just a delay of normal healing, to exposure and eventual loss of large segments of the jaw. This is potentially very serious, debilitating and can have a very long treatment time. The drugs found to contribute to dental health issues were initially in the Bisphosphonate family, such as Fosamax, but newer unrelated drugs can cause the same problems.

There has been much research since then, and we have a better understanding of the size and nature of the problem, but many difficulties remain. We know for example, that the number of years you have taken these drugs, is very important. The longer you are on them the greater the risk of developing BRON (bisphosphonate related osteonecrosis). There have been studies on discontinuing the drugs to allow for better bone healing. While this makes intuitive sense, the results have been mixed. Bisphosphonate drugs are locked into your bone and take many, many years,( if ever,) to be eliminated.

We have a better understanding of how to treat BRON should it develop, and how NOT to treat it. And there are some new drugs that can stimulate bone healing to help it resolve, as well as simple rinses and long term antibiotics which will allow many cases to heal.

What is most important is that we know you are on these medications and can appropriately PLAN. Dr. Kulaga and I, here at White Wolf Dental, stress the importance of making a comprehensive plan for your dental health. This doesn’t mean that we have to do extensive work on all patients, or that even when extensive work is needed, that it all be done at once. What it means is that we take the information from the dental exam, combine it with your health history and financial situation, to develop a plan that best suits your needs.

So, to be concrete about it, a broken tooth does not always mean a root canal and crown for everyone. A broken tooth might be treated with a bridge or extraction and implant. It may even make sense to do a root canal and not restore the broken tooth! (if we don’t want to risk problems in a patient with OP). If we know you are recently on OP medications, we might want to do any surgery relatively soon when risks are low, and defer the restorative work till later.

There are no pat answers, and this is a complex topic. The important thing is that you need to inform us about any medical or medication changes, and osteoporosis in particular. When we have all the information, we can create a plan that takes everything into consideration.

Feel free to comment on this post if you have any questions or opinions!

Dr. Joe Valenzi

The New Oral Cancer Epidemic

Doctor Valenzi

Last month I attended a lecture given by Dr. Donald M. Cohen, the division head of Oral and Maxillo-facial Pathology at the UF Dental School. Among other topics, much time was given to explaining the recent rise in Oral Cancer (OC).

Who gets oral cancer?

OC used to be almost exclusively found in people over age 65 who were heavy drinkers and smokers. This made sense since we have known for years that tobacco and alcohol are carcinogens. The longer one uses these substances, the greater the damage to the tissues, and the more likely this damage will lead to cancer. However in recent years, dentists have seen a rise in cancer in younger patients. Patients in their 50’s, sometimes 40’s, and even much younger have been diagnosed. Worse still, these patients didn’t fit the usual smoker/drinker profile. In fact, while the overall rate of oral cancer with the old profile is going DOWN, the rate of cancer with the new profile is not only going up, it now surpasses the old. The net effect is that total oral cancer diagnoses per year are now going up. What is driving this change?

It seems that this change is almost certainly linked to the spread of the Human Papillomavirus or HPV. In it’s various forms, HPV is responsible for common warts, plantar and genital warts. HPV is a very common virus that has over 100 varieties or genotypes. Of these about 11 are high risk for cancer. It is also responsible for almost all cervical cancer.

The virus is everywhere!

HPV is very common. It is the most common sexually transmissible disease. By age 50, as many as 60-85% of sexually active people will have had HPV at some point in their lives. But in most cases the infection clears naturally to an undetectable level. Whether it is truly gone is a matter of debate. It may persist at a very low level, until perhaps a change in the immune system allows it to recur.

We check all our patients for oral cancer during comprehensive or periodic exams. I think it is the most important part of the exam. You can examine yourself as well. Besides lumps and bumps, look for white patches, red patches or white/red mixed patches. If there is a something that exactly matches on the other side of your mouth, it is almost certainly supposed to be there. The ones that don’t match are the ones to watch. And watch is what you need to do. Pizza burns, tortilla chip injuries and cheek biting can look like cancer. All these things will clear up within a week, two weeks at most. If the spot persists longer than that, you should have us look at it.

Fancy Lights

Some dentists charge an extra fee to use an oral rinse coupled with a special light that claims to identify oral cancer. I have looked at these lights, and the research behind them and have chosen to not incorporate them into the practice for several reasons. For one, (and Dr. Cohen confirmed this), I’ve not found any research which shows that these lights reveal anything which is not visible to the unaided, trained eye. In fact, they cause all sorts of innocent things to glow as though they are cancer. You still have to know what you are looking at. Secondly, we would have to charge $50 or so for the materials, every exam. If I felt it would it would help us identify even one case of cancer we would adopt it. If you know our practice, you know we don’t skimp on technology. Anything that helps my patients, I buy. But I won’t drive up the cost of routine visits without good cause.

Throat cancer

HPV also causes cancer of the oropharynx, and throat as well. These are NOT areas which we dentists can see. While we can see the small area in the throat directly behind the tongue, we don’t look up into the nasopharynx, or down into the throat. If you feel a lump in your neck, change in your voice, sore throat, difficulty swallowing etc. you need to see your physician.

Vaccines

Hopefully, in the future we will see a steep decline in oral cancer from HPV. Vaccines like Gardasil, if given young enough will stop the spread of the worst strains of HPV. This will take years to really impact the current trend however.

Dr. Valenzi saves Mannequin’s Life!

hifimannequin

On March 14th Dr. Valenzi repeatedly saved the lives of several very problem prone “high fidelity” mannequins at an Advanced Airway and Sedation Emergency Preparedness class held in Orlando by the Florida Dental Society of Anesthesiology.

High Fidelity Mannequins are the latest tool to help Health Care Providers train to manage emergencies. Unlike the simple mannequins used in basic CPR training, these have a pulse, cough, wheeze, and breath. They even simulate choking and their tongues swell when they have allergic reactions.

Like pilots who practice emergency procedures on highly realistic flight simulators, these mannequins help health care professionals hone our skills for situations that we take every effort to never see!

Addicted to CE

Dr. Kulaga is a continuing education junkie! He recently attended a course on sleep apnea, and is hoping to integrate Obstructive Sleep Apnea treatments into our practice.

 

white-wolf-dental-dr-kulaga“Keeping with our White Wolf mission statement to provide patients with the best possible dental care, I have embarked on a new journey into dental sleep medicine. Over the past few years, I have had many patients ask me about alternatives to CPAP therapy for Obstructive Sleep Apnea (OSA) or I have had patients with symptoms of sleep apnea that I did not recognize. Recently, this subject has become personal for me as I have a moderate form of OSA. Things that I noticed were feeling slightly tired through the day, tired muscle joints upon waking, and frequently waking through the night. More over, my wife has noticed my snoring becoming progressively worse. As your dentist, I am not here to diagnose you with OSA, but to look for signs and refer you to the proper physicians. Once your physician has confirmed you have OSA, I can work with them to provide treatment, such as an oral appliance, the use of an oral appliance if you tried a CPAP and have an intolerance, or in some instances, the use of an oral appliance with CPAP to improve results. I look forward to helping our patients have a more comfortable night’s sleep.”

     ~Dr. Kulaga

Happy Holidays!

christmas 2013_1 christmas 2013_3 christmas 2013_2

Here are a few highlights from our office Holiday party last Friday at Port Orange Steakhouse. It was a blast; full of memories, laughs & tears! Happy Holidays to all our staff, patients, and friends from White Wolf Dental!

Tooth Truth

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