Adhesive 101

Hey all,

I had a really rough weekend. I don't know when I have been more disappointed by sports in my life. I don't know if you watched the college basketball games this weekend or not, but the Gators lost in a heart-breaker. We were winning by 13 with 8 minutes to play when we had a total collapse. I thought we were the better team (at least we were for 32 minutes of the game). I am telling you, I think I need a sports therapist.

Now every time I hear someone talking about the Final Four I turn the station (radio or TV).If I hear the word Louisville, I get physically sick. I had to kick a Louisville fan off this blog for good after she made a comment about it. I am looking into how to get her dental license revoked. She messed with the wrong blogger.

It has been a tough week for me. Saturday night, I woke up in a cold sweat (it could have been from the alcohol) at 2:30 a.m. and I couldn't go back to sleep. It gave me an opportunity to watch a movie I had, The Girl with the Dragon Tattoo. Wow, was this movie graphic. Very explicit in a lot of ways. Good movie, but very graphic. I told you I read the book and that was really good.

Speaking of books and movies, I had to take my son to see The Hunger Games because he and I both read the book. I thought it was okay. The book was so good that I thought the movie was going to have trouble living up to it. It did, but I thought it was a pretty good movie. It was a 2 and a half hour movie and when it was done I was like, "That was it? It was too short.”

Okay, topic. I told you that from time to time I am going to test-run my lecture on you guys. I have been spending a lot of time reading up on bonding agents, trying to learn the science behind them. Not to act all "la dee da," but more so I can answer questions if they arrive. If I am going to go up there and speak, I kind of have to know this stuff, even if I am not going to talk much about it.

I don't really want to spend much time on it and I don't want people to be bogged down in the details of stuff they don't really need to know. Clinicians Report says, "If you like your material and it is close to the top of the list, just keep doing what you are doing." That means that people don’t want to be bothered with the details, they just want to know the stuff they are using is okay.

But I thought the stuff I am reading is interesting enough to let you guys know about it. I will do my best to not screw up the science. And if you are a dental geek and get into this stuff, let me know and I will try to do more of it. I think I will tell you what I know today and then have a counterpoint tomorrow.

Adhesives are a big thing in posterior composites. Fourth generation adhesives were the gold standard of bonding strength. Now, 6th generations are giving the 4th generations a run for their money. The bond strength is there at the time of the filling placement (we know this), but the issue is becoming that dentin bond strength is diminishing over time. So what is going on?

Have you heard of things called MMPs - matrix metalloproteinases? Me neither. These are "a family of zinc-dependent structural and functional related endopeptidases that are capable of degrading extracellular matrix proteins." [Did I make your eyes just glaze over? stay with me.] In Gammichia speak, MMPs = bad.

Let me back up. The goal of manufacturers is to develop bonding adhesives that completely encapsulate the conditioned collagen fibrils through total infiltration of resin. Collagen fibrils that are completely surrounded by resin are protected from degradation. These are not my words. I am quoting a lot from an article written by Gregg Helvey, DDS. (By the way, this guy is in private practice. How do you dentistry all day and know this much about adhesives? Boggles my mind.)

If the adhesive does its job right, it is supposed to protect the collagen from degradation. But none of the adhesives are doing it completely. They are also saying studies have shown that host-derived proteinases also contribute to the breakdown of collagen matrices. This means there is going to be breakdown in a filling at the adhesive level. But the host of the filling has something to do with it. You and I see this every day. One filling you do starts to look like crap in 5 years and others you did 14 years ago, look awesome. In Gammichia speak, certain people you put a filling in will break down a filling faster.

Turns out, MMPs are bound to the collagen matrix in a mineralized state where they are covered with extrafibrillar and intrafibrillar apatite crystallites. While the MMPs remain in this mineralized state, they are inactive. So we are having the unprotected collagen being degraded by MMPs because the adhesive is not doing its job. In Gammichia speak, crystallized collagen = good.

Cool so far, isn't it?

Naturally, once scientists know this, they are going to try to create a bonding agent to fully crystallize the collagen, protecting it from degradation. So, scientists have found that acid-etched collagen matrixes don't degrade if in an aqueous solution of 0.2% chlorhexidine (CHX), like Consepsis. They do degrade over time, but this is definitely a step in the right direction. They are finding that the degradation doesn't start until 9-18 months after bonding. In Gammichia speak, Consepsis before the acid etch stage = good.

But 0.2% chlorhexidine (CHX) is not the only MMP inhibition. There are a ton of other things, bromide being one of them. Can you imagine if they had a bonding agent with bromide in it? That would be smart.

In fact, the people at Kuraray are way ahead of us. This is something else that boggles my mind. I am hearing about this MMP stuff for the first time, yet they already have a product for that. That means the research has been done on MMPs. That means all the research and development has been done on a product. That means the product has been made and is available all before I hear about MMPs.

There is a product that is called Clearfil SE Protect that incorporates bromide. That means there is a product that is Clearfil SE plus an aqueous solution of bromide that fully crystallizes the collagen, protecting it from breakdown.

How can we do more? How about releasing fluoride in an adhesive? Well, guess what. They have thought about that, too. There is a product called Clearfil Tri-S Plus. That is, Clearfil SE+bromide+fluoride. Incredible right?

Okay, let’s stop there for today. My head hurts.

Have a great Thursday.
john

An Ounce of Prevention

OH MY GOSH!!!! I am dying over here. To quote Joakim Noah, "Those Gator boys are hot!" The Gators won their game last night. This game ended at 12:45 this morning, but I am floating on the proverbial cloud nine. I wore my Gator Basketball T-shirt to work today and refuse to take it off.

Now, here is my ordeal. As you may know, I am a Gator Basketball season ticket-holder. I would be first in line for Final Four tickets, one of the premier sporting events of the year. Don't get me wrong: I am not counting my chickens before they hatch. I know that there is one more hard game we are going to have to win to get the basketball promised land. But it is fun talking about it. I, of course, would want to go the Final Four in New Orleans this year. The semi-final games would be next Saturday and then the final game would be Monday, April 2nd. There is just one small catch. I have Master's practice round tickets for Monday, April 2nd. Oh my gosh. This is definitely a great problem to have.

Wow, I can't even type I am so excited, but I will try. I want to talk about people brushing their teeth. I work in a suburb of Orlando. I am not bragging, but I think we are kind of an upscale practice with a small-town feel. When you walk into my office, things are nice. We have nice impressive furniture, comfortable leather chairs, we even have a leather massage chair (that people fight over). So it always baffles me when I see people that don't brush their teeth. And it comes in so many sizes.

In my new patient exam, I bring the patient into a room just to talk. I ask, "How do you take care of your teeth?" You would be surprised by the answers and by who is giving them.

"I brush about twice a week."
"I brush once a day when I wake up"
"No, I don't floss. It makes my gums bleed"
"I know I should be doing it more"
"What? Is that wrong?"

I try not to raise an eyebrow, but I think the ADA and AGD have done a good job at educating and I think most people know that BRUSHING YOUR TEETH TWICE A DAY IS GOOD FOR YOU!!! I mean, I am teaching my two year old basic oral hygiene. And most people hate coming to the dentist. Do you know how you can avoid coming to the dentist? Yeah, BRUSHING YOUR TEETH!!! This is not rocket science.

I am working on a person this week that has #7 broken at the gumline with decay on 6, 8 and 9. This person is getting ready to have a 4-unit, almost $5,000 bridge and has plaque all over their teeth. I don't know how many times I have to go over OHI with people.

And I am sorry, but I am not the guy who is going to tell a patient that I am not going to do this bridge until they can get their oral hygiene under control. I will tell them (and continue to tell them) that if they are not going to brush their teeth, the bridge is not going to last. I have even made people sign paperwork saying that they have heard me.

Then there is the person who doesn’t have a little plaque, but more like a week’s worth of plaque on their teeth. When I mention it, they get frustrated and say, "I brush my teeth!" Then I have them look in a patient mirror and show them the plaque I am getting off with the explorer. They act like they have never looked in a mirror before.

Listen, I am not biting the hand that feeds me. I am happy when people don't brush their teeth. I am happy when kids eat Skittles and Ring Pops and suck on Mountain Dew all day (I am being sarcastic. I really don't like it. In fact, it really bothers me). But we are talking adults here.

A couple years ago, I resurrected a patient’s mouth. I did 12 fillings, a root canal and a crown. It was thousands of dollars worth of work, but things were looking really good. Well, I saw her yesterday, and now two years later, she has 10 cavities on the facials of posteriors. She claims to be a Coke drinker and a smoker. And, of course, it is going to be a struggle for her to pay for all these fillings.

Brushing your teeth is the simplest form of prevention. It is like wearing a seatbelt in the car. It is so easy. Maybe you are not doing it right. Maybe you are not doing it long enough. You go to the dentist, the hygienist tells you so, and you get better. It is easy.

I would like to think we are getting smarter. I like to think that people want to get better. I would like to think that people will do things or not do things to make their lives easier. But then I drive down the street and see how many people don't wear their seat belts. I drive down the street and see how many people are smoking (they must be the ones not brushing their teeth).

Are you seeing this in your practices, or is it just me?

Have a great weekend.Remember, root for the Orange and Blue on Saturday. I will be in a much better mood on Wednesday if we win.
john

Another Day In Paradise

Hey all,

Hope you had a good weekend. I did. Did anyone watch the Gators put a beatdown on Virginia and Norfolk State? SWEET SIXTEEN, BABY!!!! I am wearing my orange and blue today because our dance continues tonight. Our game starts at 10:17pm, my time, so I am going to be really angry and tired tomorrow or on cloud 9. Let’s hope for the latter.

I watched a couple of movies this week. ("When do you have time?" you might ask. Well, when you are up at 3:30am worrying about life and dentistry and kids, you find a lot of time.) I watched Kinky Boots. No, it wasn't an adult movie. It was foreign film (in English, thank goodness) and I have to say that it was pretty good. I also watched The Beaver. This had a star-studded cast: Mel Gibson, Jody Foster and Cherry Jones. This is a movie that Hollywood loves but I HATED. It was everything I could do just to finish it. Don't even waste a slot in your queue.

Okay, I just finished reading the latest AGD Impact , and it had an article in it from a 4th year dental student, Maggie Law. And as I sit here exhausted from a very tough day, I don't exactly know if Ms. Law really knows what she is getting into. I had a day that you read about, a day where you go home and just sit on the couch until you fall asleep.

It all started with a snow bird. Snow birds are northerners who come down to the south for the winter. She came in last week to ask me my opinion on a broken tooth. She had broken #29. The tooth had an MOD amalgam in it, but the filling fell out and the buccal cusp went with it. And the ling cusp was also loose. I took an x-ray. On the x-ray, she had a military grade amalgam build-up on #30 with decay under it and #28 had a huge DO on it with decay under that (oh, she had just gone to the dentist about 3 months ago).

I told her that I thought she needed three crowns. By the time we were done discussing, I told her I could do huge fillings on #30 and #28, but #29 was going to need a crown and whether or not she was going to need a RCT and post and core was going to be a game-time decision.

This morning she came in to do the work. Things were going great. I took out all the amalgam and decay and was going to start on the build-up on #29. The tooth looked like a small teepee. I wasn't going to get a build-up on there. I thought a second. I had heard from Gordon Christensen that he is doing more pins again, and I thought this would be the perfect case. I was just looking for a couple of mm of core material. The tooth had ferrule, but no retention.

I put a hole in the buccal and the ling. I put the pin in the buccal and when I went to put the pin in the hole in the ling, I saw the tooth break right before my eyes. The ling part of the tooth between the gums and the hole sheared off. And it didn't just break; it broke below the level of the bone.

I felt like this was a great time to go and check hygiene. I was so mad, my blood was boiling. I came back, much calmer, and proceeded to do the fillings on #30 and #29, which both turned out tres magnifique, if you ask me.

But I still had this broken tooth to deal with. I gave her options. I was very up front with her and told her everything that happened. I looked in the x-ray and the tooth was very long. The first option was to send her for a crown lengthening procedure. Or I could take it out and do a bridge on the two teeth she needed crowns on anyway

She asked me what I would do. I told her I would do the crown lengthening and then just do one crown. She agreed. But now she is only here for about 3 more weeks and we all know that after you do a procedure, you can't mess with the tissue until it matures and that takes longer than three weeks. Arrrggghhh. We decided to do a build-up, and prep the crown prep in the build-up and put a temp on that.

Then, a second patient. A patient I have had since I was a rookie out of school. I had a lot of patience then. She is a crier, a mover, and a talker. Don't get me wrong; I really like her and she really likes me, but she is a tough patient to work on. She lives in Washington state and comes to see me when she is visiting her brother that lives in town. Last week, she came in for a "get reacquainted" exam and today we were going to clean her teeth and deal with the three spots of decay she had.

I guess I don't have as much patience as I did back then. Working on someone that is sucking nitrous as hard as they can, kicking off their shoes, shaking their feet and talking, all at the same time, is very difficult for me. I mean, when I was done with these things, I was totally spent and she was only my second patient.

My day calmed down but revved back up when little Billy ended up in the chair. Billy, who is 8, started asking me why I felt like I needed to take an x-ray. He then proceeded to tell me what Dr. Oz told him about protecting the thyroid when taking an x-ray. Billy needed a filling and we were going to do it today. BBut after a local of Septocaine, it appeared he wasn't numb. I then gave him a block, much to his dismay, and he still wasn't numb. By now, Billy no longer wanted to be in my chair. But Billy had a big hole in his tooth. This was not going to the easy, 15-minute appointment I told his mom it would be.

Billy made it, but I am not sure about me or my assistant. I think I saw her with a 40 wrapped in a paper bag coming out of the 7-11 across the street.

Man, I had a tough day. Now add that to a day when your bill payer is in (yes, that was today) and she is telling you that payroll is next week and it is not looking so good. And a day when you had three hygienists and a bunch of hygiene checks on people that want your best. They don’t want the tired, just broke a ling cusp off a tooth trying to put in a pin guy that you feel like.

I know dental school is hard. It was the best and hardest 4 years of my life. Until now. I don't even know how to prepare the young dentists of today. But I can tell you one thing: as soon as you start working here, I have three patients I am sending your way.

Have a great Thursday.
john

Study Club

Say it with me: Friday!!!

I don't know if you are into it or not, but the NCAA basketball tournament is in full swing. My Gators play today and I am not really feeling it. But, as you know, what happens before the tourney doesn't matter. You could get hot at the right time and next thing you know, you are National Champions. Last year, VCU was in a "play-in" game and three weeks later they were in the Final Four. I can only dream. Our game is at 2:10 today. I can tell you that after 2pm today, productivity is going to go way down here.

I watched a foreign film last night called Kinky Boots. When I first started watching it, I wondered, "What the heck was I thinking putting this movie on my queue?" But I watched it and I was pleasantly surprised. I thought it was really good.

I belong to the local chapter of the Seattle Study Club here in Orlando. I have been in a bunch of study clubs, but when I go to this one, I am a bit intimidated. I have been through all the Pankey Continuums, but I have to admit that I have lost some of it. There are some prosthodontists there and some big wigs of Orlando. These guys are good.

There was a meeting yesterday, and there wasn't much going on. It was just two of the members getting together and giving a case presentation. One of them had been a Kois instructor and one is presently a Spear instructor. They described what they do for a new patient exam. I do a lot of the same things on my NPE: perio, occlusion, decay, TMJ. But they are doing it with a lot more pizzazz. Their diagnosis is so much more complicated.

Here is my thing: I will do all this examining and most people will be okay. I think out of the last four people I have done a NPE on, there was a need for three fillings...TOTAL. They all have good occlusion, good perio, good everything. They were fine.

What if the next person comes in and they are a train wreck? You ask them what their chief complaint is and they say they want their teeth bleached. This is the fork is in the road. Some dentists will say, "Do you want the in-office bleach or the take home?" And some dentists will try to "turn this ship around," so to speak.

Everyone that comes out of a Spear course or a Kois course or a Pankey Continuum is pumped about "turning ships around." But after 50 of the 50 ships look at you like you are crazy, you start to think you are crazy. You can't help but start to shy away from this type of dentistry. (Meanwhile, you had 50 people come to you that heard you were awesome and now only 10 of them still come to you and the other 40 say, "He was crazy, he wanted to do something like $25,000 worth of dentistry on me, when I went in there for bleaching trays.”)

At the case presentation presented yesterday, a lady came in with worn anterior occlusion and wanted to fix her anterior esthetics. They did a full work up. This type of case is pretty easy.Patient wants it, you do it. Crown lengthening, bone grafts, implants, temps; she had beautiful crowns when she was done.

How many people come in, nowadays, that are looking for "All the kids are gone and I want to take care of myself" type of dentistry? Not many for me anymore. I find myself doing "meat and potatoes" dentistry, trying to find my niche in conservative dentistry. Meanwhile, the next person that needs "a new smile" won't hear about me because I no longer have that reputation. The beginning skills I had in doing Spear- and Kois-type dentistry have diminished enough to where I get a little scared doing this type of dentistry. Maybe I don't know enough to treat this person right. Am I making sense?

But the take away I got was that these people are in my practice. The 40-year-old person with extremely worn anterior dentition doesn’t even know they need a full-mouth rehab. They trust me but don't even know what is going on in their mouth. I am going to start taking photos of these people to at least let them know what is going on. This is where I am going to start. No pressure on me. Just letting them know. I at least feel comfortable doing that. For now.

Have a great weekend.
john

Technology

Hey all. I hope you are having a good week.

About 9 months ago my wife bought a new Samsung android phone. It was time for an upgrade, so we got a $499 phone for $125 (with a 2 year agreement). She had it about 2 months when my son dropped it and busted it to smithereens. We knew the glass was cracked, but the manufacturer deemed it “unrepairable.” Since we didn't buy insurance, we would have had to buy a new phone for $499, not $125. Instead, we borrowed an old phone and have been limping along with this one until someone was up for an upgrade.

I was finally up for an upgrade, so yesterday I got a new iPhone 4S and my wife got my old iPhone 4. Now listen, I am not into all the bells and whistles kind of stuff, but I have to admit that SIRI is pretty cool. The iPhone 4S really isn't that much different than the old iPhone, but the voice command software (called SIRI) is infinitely better.

You can do most things without actually having to touch the phone. You put the phone up to your ear and say, "Call Eric Smith's cell phone," and it will call. You can say, "Text to Eric Smith’s cell phone: 'I think we have a meeting tonight at church.Can you call me and tell me what room the meeting is in, please?” And it will type out your message with NO MISTAKES and send the text. You can tell SIRI to add something to your calendar, and it will tell you if you have any prior commitments that would coincide. So far, after about 50 commands, she has not even gotten one word wrong. It is a lot like the commercial. It is awesome.

But how would I be without SIRI? Yesterday I was just doing fine. In fact, my wife who was using an iPhone 3 for the last nine months was doing just fine, as well. And as cool as SIRI, is I don't know how much better my life is going to be with her. The camera is probably a little better and the capacity of the phone is probably better, but it really is just a phone.

This is the case with everything. Let’s look at cars. Now you all know that I drive a 2001 Ford F150. I love this thing (mainly because it is paid for and it hasn't given me any trouble in a long time). The only bell or whistle this thing has on it is that it has power windows. I am exaggerating, but as far as MP3 player hook-up, in-dash CD player, computerized traction, heated seats, beeping, when in reverse or going side to side when you are about to hit something, there is none of that. There is no digital read out of MPG or how many miles to go on a tank of gas. You get what I mean. But you know what it does do? It gets me to work every day without question (and Oh, I don't have to pay for all those bells and whistles). Am I missing something by not getting a new car? I don't exactly know because I don't have one.

It is is the same with the phone. And now I am going to bring this home with some dental stuff.

I alluded to my computers in Friday's blog. I have 6-year-old computers. I stopped getting the EagleSoft software updates because my old computers could not handle the upgrades. Am I missing anything? I don't know. I know that I work on EagleSoft XII and they are on EagleSoft XIV (or something like that).

I called my computer guy and asked him how much it would cost to upgrade my three front desk computers. I guess they are Dell desktops computers on steroids. He told me the specs. I looked it up on Dell, and I could get the computers for about $650 each. Yet his estimate was $4,500. It is about a day of labor for one of his guys. There might be some extra stuff he has to buy, but that is a dentist-like fee.

I don't have that right now and, quite frankly, I have had this estimate on my desk for about 6 months and don't see myself pulling the trigger on this for a long time. My computers are pooping out every once in a while, but I pay the guys to come out, do their thing, replace a part, and I am back up and running.

Look, I know I am selling him short. I know that he has a lot of skill and does his skill very well. And I appreciate a guy with skill who is familiar with my systems and returns my calls. I am sorry if I didn't sound like I did.

This blog is not about the fees of my computer guy. It is supposed to be about technology and whether or not we really need it. If we are missing a bell here or a whistle there, are we doing lesser dentistry? I think that depends.

And, as seen with my computer issue, technology costs money. Money gets in the way. “Will this make me a better dentist?” becomes “Can I afford this thing that will probably make me a better dentist?”

A good example of technology that is a must-have is an LED curing light (in my book). Another is Loupes. And right up there is a headlight. Then there some things that are wants but will not necessarily make us better dentists. A CAD/CAM machine would be awesome. How about digital impressions? A digital panoramic machine would be nice. I wish my hygienists had loupes.

How about computers in general? Maybe some of you are thinking about making the jump to paperless. Let me tell you: I am there and it is really, really nice not to have charts. But does it make me a better dentist? I am not going to answer that. You have to.

What do you all think?

Have a great Thursday and I will talk to you tomorrow.
John

Loan Shark

Happy Friday,

It is official: I am buying my dad out. I am telling you about this because I think there might be a lot of dentists out there wondering about the process. I have a financial adviser that I pay quarterly to be the point man when it comes to things like this. He watches our practice. He knows our practice.

When we told the adviser that we were going to do this, he put a package together. The package includes all the numbers of our practice, production, overhead, profit, salaries, P/L. It also includes a business plan, my W-2s for the last 5 years, and all that stuff that I try not to get too involved with.

After we put the packed together, we had to think about whom we would allow to compete for our loan. We have been customers of a certain large bank since my father started this practice (it was a smaller bank then), so we started there. There is a bank literally across the street from my office. The manager has been a patient since before I was here, and a couple staff members there are also patients. There is a guy from my church that everyone knows around town. He is boisterous, fun, and very excited about working with me, so we put him in the mix. I have another patient that is high up at another bank, so he’s in the mix. There is also one more that my financial adviser has a long time relationship with.

We sent the package to these five financial institutions, and my life has not been pleasant since. I wake up in the middle of the night thinking about making payments. I am grouchy at work because I think about overhead like I never have before. I used to make fun of dentists that micromanage their offices and here I am doing it. I hear myself saying to my assistant, "Do you really need to put out that many cotton rolls for this procedure?"

or

"Two drops? Really?! Two drops? Do you really think we are going to need two drops of Clearfil for this procedure? Of course you don't know. Because you don't care. Why would you? You don't have THIS HUGE LOAN HANGING OVER YOUR HEAD FOR THE NEXT SEVEN YEARS!!! Of course you don't care about how many drops you put in the dappen dish!"

Are these words really coming out of my mouth? Did I really just go up to the front and tell everyone to get back to work and stop talking and laughing? What is happening to me? Is this what becoming the 100% owner feels like?

I start to look at all the products we have. I look at the 6-year-old computers and just look the other way. I look at the rug that needs to be replaced. I am seeing everything as a monkey on my back. I know it is not supposed to be this way. I know that this is supposed to a happy time. I know that this was the natural progression of my career. I knew five years ago that this was coming. But why is signing the papers changing me? Why do I go home and mope?

It has even made me less tolerant of my kids. "Are these your broken crayons? Who do you think has to pay for all these crayons? Do you even care? Of course you don't, because you don't have this THIS HUGE LOAN HANGING OVER YOUR HEAD FOR THE NEXT SEVEN YEARS!!! Of course you don't care about how much crayons cost!" Man, kids these days.

Things look expensive at home, too. Cars, dishwashers, rugs that are 10 years old. I know owning a house costs money. I know that things need to be replaced, but they all seem to need replacing as I am getting ready to sign this big loan.

The loan is, relatively, not that much and if the office stays the same, things should be fine. But if we slip a little… Ahhh, I am starting to sweat just writing that.

Things at the office are okay, but we are not doing that great. We are getting very nice people in and patients that really appreciate what we are doing here. I have always said that that is my motivation. But, now that all this going to be mine (or, now that I am on the hook for all this), it feels different. I just want to sign the papers and get it over with. I want to get a couple of months of paying it back under my belt and maybe this headache will go away.

On a more pleasant note, I was approved by all five banks. Two of them have been very competitive. The rate I am borrowing this money at is very low, so I’ve got that going for me. But this doesn't unwind me at all. I wish I had all this money in the bank so I didn't have to borrow. I wish I was on the other end where I was deciding what to do with my money and where to invest. Should I buy real estate or a mountain home? Not this. This is too stressful.

Have a great weekend,
john

Do you know how much crayons cost nowadays?

Is it Hot in Here?

Hi all,

I hope all of you had a less eventful weekend than I did. I was busy. Friday night was a 50th birthday party. Saturday, I woke at 4:10 a.m. to go for a long run (18 miles). I was at the ball fields for a 9 a.m. game, then to a funeral at 10 and lacrosse game at 11:30. Then I had a couple hours to do chores before I got the green light to go to the Magic game.

Woke up Sunday and got in the car at 8 a.m. to see the UF vs Kentucky basketball game. Sucky outcome, but great times. Did I tell you that I am a huge Gator basketball fan? This year, the band was moved to the second level which opened up a bunch of seats on the first level. I somehow got awesome second row seats.

You have all seen the "face guy" from the Alabama student section. Well, I had this idea since the beginning of the season, but I just never did it. I actually had my face at the printer when this guy broke. I had my poster face made and this is what I looked like at the game You will see I busted out the throw-back jersey and the orange and blue scarf (not really manly, I know) to see if I could muster up some old school luck. Didn't happen. Here is what it looks like during free throws:



Pretty awesome, huh? This was on the Gainseville Sun website.

Friday's blog was on an emergency I had on Friday afternoon. I have to say that my wanting to take this tooth out for this man (and it wasn't about money) so he could get a good night sleep clouded my judgment. This was a man who was 56 and had a very complicated medical history. I don't' have to make excuses. I probably would have done it differently if I had a chance. If I could do it differently, we all know I would refer him. There was a really good comment about the pros and cons of working on a patient like this. The commenter basically said it just isn’t worth it.

But I am always about growing. I have been looking at how I treat people's health as a whole. I have to admit that I am a bit cavalier when it comes to people's health. I have discussions with people at my new patient exam. We discuss anything medically that is going on in their lives.

For an emergency appointment, I still discuss their medical history and meds. Other than a patient like I had on Friday (56, three strokes, 14 meds), no real red flags go up. (By the by, I called the wife and it turns out that he just fainted. He got the tooth taken out yesterday.)

I don't know if I would change much. I don't know what on a medical history would really throw up some red flags. High Blood pressure? Are you checking blood pressure on everyone? One comment said, "Please tell me you took his blood pressure?"
Okay here is my thing about blood pressure. I don't buy it. I don't buy that if someone has high blood pressure 5 minutes before a dental appointment they are at risk. I am about as fit as they come. I am a marathon runner.

I went to my physician for a physical. She took my blood pressure and it was high that morning. I was shocked because I have never had an issue with that. I wasn't nervous or anything. Turns out that I had a cup of coffee about an hour prior to the appointment and that raised my blood pressure.

Now, if we are checking blood pressure, are we sending people home if it is high? And what is high? Anything over 140/90? Do you tell them that they can't be seen in your office unless they get that blood pressure under control? That would mean we are sending home everyone that has had a cup of coffee before their appointment. And if they are a little nervous and had a cup of coffee? Have 911 on speed dial.

What if the patient hasn't seen a doctor in about 15 years, like most 40-year-old males, and they just don't know how healthy they are? (I guess this would be a great reason to take the blood pressure.)

Yes, I am being a little sarcastic. Yes, I understand the need for being diligent. I am just playing devil's advocate here.

I went to the doctor the other day when I wasn't feeling well; they took my pulse and blood pressure. She said my pulse was 65 and my bp was 125/80. I knew that was wrong. I am a runner and my pulse has been in the 40s for the last 6 years.

When I went to the pharmacy to pick up my prescription, I sat in one of those machines. Sure enough, pulse 47 and my blood pressure was 117/70. If a doctor’s office can’t get a nurse that knows how to take blood pressure...

How about blood thinners? Are you sending people home for being on anticoagulants or antiplatelet meds? And if you are or are not, where are you getting your info from? I don't know squat about meds, so I make no decision on my own. I called my periodontist and asked him if he takes his patients off blood thinngers before a cleaning or extraction.

He said, "No." He said he would rather them bleed a little after an extraction than stroke out. Hmm. So we don't have anyone come off blood thinners before a cleaning or a simple extractions here.

What about diabetes? Are you checking blood sugar? I ask, if they have checked their sugar today and if they have eaten but again, no real checks. What about if people have a history of fainting?

I am at the one side of the scale when it comes to med history. What are you guys doing? Are you easily sending people away for fear of a lawsuit? Or fear for the patient’s overall health?

The only thing that would require me to tell the patient that we can't work on them (on a regular basis) is artificial joints (knees, hips and the like). They can't be seen here without an antibiotic one hour before their appointment. Also, I usually send out medically-compromised patients (like the guy that was here on Friday). Like the commenter said, "All this for a simple exo fee, thank you, no."

Anyway, tell me how you deal with overall health. What do you send people away for? If you never send someone away, I want to hear you too.

Thanks. Have a great Wednesday.
john

The Big Valley

Greetings,

Well, it is day six in what is now known as “the copper pipe fiasco of 2012.” Let me back up a few days. We walked into our house at approximately 7 p.m., and I noticed there was a slight “squish” in the wood floor. My mind is not real quick these days, but in a fraction of a second, two scenarios were going through my head. Either my Great Dane had “the mother of all accidents”, or there was major leak going on in the house.

Upon further investigation, it was determined that a copper pipe under our concrete slab had ruptured. The only way to stop it was to shut off the water to our house. I have learned a couple things so far from this incident.

1. We are all creatures of habit. Have you ever forgotten your watch at home, but looked at your wrist 20 times to check the time? I know we have no water, but every single time I walk to the bathroom sink, I reach for the handle and turn it on.

2. Water is life. I never realized how much we depend on water. I now appreciate what the Pilgrims had to go through. My wife’s dream has come true, she always wanted to be a pioneer woman (she watched too many episodes of The Big Valley when she was younger and still thinks she has a chance of being Mrs. Nick Barkley).

We have washing dishes down to a science. I go down to the well and fill up old gallon jugs. Mrs. Barkley gets out the big pasta pot and boils the water I bring up from the well. We have a washing station and a rinsing station in different areas of the house. I am just waiting for Michael Landon to walk in from Little House on the Prairie and ask when “the vittles” are going to be ready.

We have no counter tops now. The kitchen cabinets have been ripped out because the water wicked up into the wood and drywall behind the cabinets. Soon the plumbers will come in and tear up the house with new pipes and shortly after that, the wood floors will be destroyed and replaced. I am so glad I decided to put a shower in my dental office when I built it 6 years ago. I wasn’t even sure it was going to work because I have never used it. My original plan was to jog at lunch for 20 minutes, then take a shower before I saw patients (Right. Like that was going to happen—see my blog titled “Resolutions” dated January 9, 2012.)

The good news is that the shower works fine. The bad news is that, I barely fit in the thing. I am not a very big guy, but this shower is so small that I can barely move. If I slightly lift up my arms, I hit the walls. Because of the space limitation, I tend to concentrate a lot in the chestal area when showering. [Is chestal a word?]

I realize things could be a lot worse. As we have been going through this ordeal, my daughter’s friend was in a bad car accident and is now clinging to life in a hospital room. I guess having to walk to the well and get jugs of water is not as inconvenient as I first thought.

Another thing I am thankful for is our pool. We may not be able to drink the water, but it’s great for flushing toilets! In my house right now, it’s kind of hard to hide the fact that you are about to use the rest room when you are walking down the hallway sloshing a big bucket of water. So, for at least another week, we will be living The Big Valley life and I will keep seeing my patients with my really, really, really clean chest.

Have a great week.

Scott

Call 911

I am feeling so much better. I was so sick when I wrote Wednesday’s blog that I was begging for the day to be over. By about 2:30 p.m., I started to sweat while working. About 20 minutes later, it was like a miracle. I was feeling so much better.

I had already had made a doctor’s appointment for the next morning. I went to my appointment anyway and was feeling pretty good by the time I got there. She gave me a Z-pack because she thought I might be harvesting a post-viral bacterial infection. My glands were still swollen and I was still having pain on swallowing. A day and a half later, I feel like a million bucks. It makes me not take feeling well for granted.

Today, I was having a normal day. Got patients coming and going. Some were actually walking in. A man walked into my room and he was swollen on the lower left side. He told me that he hadn't slept at all last night. We took an x-ray and then I started talking to him about his medical history. He has had three strokes. He is on an antiplatelet medication, aspirin, and about 4 other meds for his heart. Oh, and he is 56 years old.

Looking at the x-ray, he has a molar crown that has history of a root canal and crown with through and through decay and abscess all around both roots. The tooth needed to come out. This guy, although not in good shape medically, is having a dental problem that could possibly make his fragile health even worse.

I looked in his mouth and pushed around looking for spontaneous bleeding. Things looked okay. I wanted to get this tooth out, so I told my assistant I wanted topical. She looked at me and said out loud, "Where do I sign to say that I am not responsible?"

"Shut up and stop telling me what to do." I numbed him up and realized he had lost his color. I asked him if he was okay. I started to talk to him to make sure he was responding to me. We were having a conversation. I started to numb the tissue around the tooth. He told me that he has always hated the dentist and always gets nervous around needles. He asked to sit up, and this is the time I thought I might be in trouble.

He was sitting up and we were still having a conversation. But for safety’s sake, I called out to the reception area and had his wife come back. She was a trooper; she had obviously been down this road before with him. She started talking to him and he started to fade. He was sitting up and passing out at the same time. She said, "I think you better make that call." WHAT!!!????

I said as calmly I as could, "You mean call 911?"

And she said, as calmly as she could, "No, I mean call Domino's pizza and get some lunch while my husband is here dying in your chair."

No, she didn't say that. She said, "Yes, call 911."

While I was talking to the operator, he had come to and started feeling better. He was saying all the things that dudes say when they pass out. "Did I pass out? Are you going to make me go to the hospital?"

He really was fine and he was talking, but I still put in him in the Trendelenburg position and had him breathe oxygen until help arrived.

The guys came in and did their tests. They hooked up an EKG machine and blood pressure cuff and did their exam. Heart was good; blood pressure was little high but okay. Then they asked him what he wanted to do. He looked at me and asked me if I wanted to go ahead and finish. I said, "No fricking way."

The paramedic said, "Everything looks okay, I would recommend you going to the Primary Care physician when you get a chance. But for now let’s have you just stand up and see what happens." He stood up and, about 3 minutes later, he started to fall over. We made him sit down and the paramedic changed his tune. "I think you should go ahead and ride in bus to the hospital." They brought the chair in and wheeled him out.

I guess if you are going to have an emergency, this is the kind to have. You don’t want the kind that require CPR. Or the kind where lawyers have to get involved in later. Having the guy talking and laughing on his way out is definitely the way to go.

Just a great way to end a really crummy week. Now I have a good reason to hit the sauce tonight (I am not going to tell you how the AGD feels about drinking your stress away. I make that up by the way).

Have you had this happen to you? Anything crazy? Tell me, tell me.

Have a great weekend.
john