Baby Tooth Trauma - endo
Q: My two-year old fell and bumped her front tooth. When it happened the gums bled a little and the tooth became loose. After a couple of days, everything seemed fine. Now, one months later the tooth is turning gray. What should I do?

A: Unfortunately, your daughter's tooth may not survive the trauma without treatment. Every tooth has a blood supply that enters through the root tip and forms a bundle within the tooth called the pulp. When a tooth is traumatized, the force of the root being pushed into the socket causes the "pinching off" of the blood vessel between the bone and the tip of the root. The blood that was already in the tooth begins to break down and releases iron and other bi-products. This then begins to turn the tooth gray or brown. Eventually a bacterial infection occurs within the tooth, leading to a dental abscess. This will usually involve pain and may negatively affect the development of the permanent tooth within the bone.

The tooth should be evaluated by a dentist and most likely a root canal would be performed. If the permanent tooth was nearing eruption (around age 6) then an extraction would likely be recommended. Due to the child's age (2), treatment could be performed by a Pedodontist or your General Dentist. However, some General Dentists routinely refer this type of treatment to the Pedodontist. A consultation with your regular dentist would be a good starting point. Every child's tolerance to treatment is different, but with good communication skills, treatment can go quite well. A child will pick up on a parents apprehension so sometimes it is best if the parent is not directly in the treatment room, so the child is forced to communicate with the dentist and dental assistant.

Root canals on baby teeth are very different from those on permanent teeth, since the baby tooth root must be allowed to dissolve as the permanent tooth comes in. In conjunction with the root canal treatment, various techniques can be utilized to whiten or mask the darkened color of the tooth. Though this may not be the easiest of tasks on two year old, I have found that children are not traumatized by it, and the retention of the tooth is a great reward for the hard effort.

Biting Pain
Q: I have a tooth that only hurts when I bite down on it with certain foods, and then the pain goes away. What do you think could be the problem?

A: This is one of the most common problems that dentists see in their offices. There can be several reasons why a tooth becomes sensitive to biting and there are different tests that can be performed by your dentist to help pinpoint the problem. Every tooth has a nerve, unless it has had a root canal. This nerve gives your tooth the ability to let you know when something is wrong. You are correct by not ignoring the problem. Listed below are some of the common problems associated with pain only when chewing.

1. A high bite on a recently placed filling or crown: This can occur on the treated tooth or on the tooth which bites against the recently treated tooth.
2. A cracked tooth: A cracked tooth will hurt when you bite down for a short moment and most often will hurt worse when the pressure is released.
3. A loose filling: A loose filling will move when you bite down causing pain.
4. Decay in the tooth: Often times teeth with deep decay will hurt when biting down.
5. Sinus Infection: Upper back teeth will often hurt when there is a sinus infection. It is important to determine if an abscessed tooth is causing the sinus infection, or if the sinus infection is causing the tooth to hurt.
6. Clenching and Grinding: Clenching and grinding will usually make several of your teeth sensitive to biting at the same time. Even if you don't think you are clenching or grinding, you may be doing it at night while you sleep.
7. An unbalanced bite: The teeth are supposed to share the load of your biting forces and they are supposed to bite together in a certain way. If the bite is not balanced, certain teeth will be over stressed and will become sensitive to biting pressure.
8. An early abscess: A tooth with an early abscess, or dead nerve, will become sensitive to biting. Eventually the pain will begin to linger and will begin to hurt even when you are not biting.

As you can see, a simple symptom of pain when biting is actually a complex issue with several possible causes. You have to be a little patient as your dentist may have to go through a process of elimination in order to determine the actual cause of the problem. Giving detailed information regarding when, where, how long, and with what, will help your dentist develop a diagnosis more quickly.

Bridge Vs Implant
Q: I have a missing tooth that I want to replace. I can't decide if I should have a bridge or an implant. What should I consider when making this decision?

A: There are many factors to consider when making this decision, and you are smart to be giving it some careful thought. Assuming conditions are appropriate for both options, there are four remaining factors to consider. These are function, longevity, esthetics, and cost. I have listed each of these individually.

1. Function: An implant retained crown (IRC) does not depend on the adjacent teeth for support. A bridge is retained by crowning both of the adjacent teeth; the artificial tooth is suspended between the two crowns. As far as chewing, both are going to be very similar. Cleaning an IRC is easier because you can floss between the teeth. You must thread floss under a bridge, and this can be difficult depending on where the bridge is. If the adjacent teeth are un-restored , or in very good condition, then it is a shame to have to alter them in order to hold a bridge. An IRC would not alter the adjacent teeth.

2. Longevity: Clinical studies show both to be acceptable treatment options if appropriate guidelines are followed; however, the IRC is proving to be a more dependable long term restoration. This is probably the case because titanium implants do not decay, and IRC's are not dependant on other teeth.

3. Esthetics: Both Bridges and IRC's can be very beautiful tooth replacements. The titanium implant will continue to stimulate the bone and therefore will prevent the bone loss that is associated with tooth loss. On a bridge, the gap between the gums and the fake tooth will usually increase with time and become less esthetic. The bone underneath actually shrinks due to lack of stimulation. An implant replaces the function of the tooth root and prevents this gradual bone shrinkage.

4. Cost: The cost of an IRC is usually higher for patients because most dental insurance companies do not cover the cost of the implant. They may however, cover part of the cost of the crown which attaches to the implant. The actual cost comparison is difficult to generalize and must be determined on a case to case basis. The number of teeth being replaced, the type of insurance, and the quality of the bone and surrounding teeth, all will influence the treatment needed to obtain a good result.

Replacing a missing tooth will restore stability to the dental arches and prevent other teeth from shifting into the empty spaces. This shifting can cause a cascading set of problems which are best avoided if possible. No matter which option you decide on, regular maintenance following the tooth replacement will protect your investment.

Broken Appointments
Q: I was furious when I had to work overtime and my dentist charged me for missing my appointment. Is this typical?

A: Many dentist and doctors are now charging for broken appointments without 24 hours notice. Some may look at the circumstances associated with the cancelled appointment and/or the frequency of cancellations for an individual person or family. It is important to realize that dental appointments are often scheduled for long periods of time, which are reserved exclusively for you. When an appointment is cancelled at the last minute, the dental office has no ability to fill that appointment. Other patients who may be waiting for an appointment can't often be contacted to fill an appointment at the last minute. The dentist must also pay their staff whether a patient is in the office or not, therefore idle time is very costly.

To help you understand consider this scenario. You woke up at 6:00 in the morning and went to work and punched in at 7:00. At 7:30, you find out that the parts you were supposed to install that day will not arrive until 9:00. You are then asked to punch out and wait, on your own time, for them to arrive. How would this make you feel?

In the situation you described, you worked overtime and probably got paid time and one half. Your dentist has lost due to idle time wages for several employees. Yes, I think being charged for a broken appointment is very reasonable, especially since that charge doesn't usually come close to covering the per-hour overhead expense of a dental office.

Can't afford dental work?
Q: Please help-I need a lot of dental work that has to be done. Yet, I need to know where I can go to get dental work (crowns, root canals, bridges) done at low or discount cost. I do not have dental insurance, nor can I afford the cost of such work, for all dentists want part up front before work and the rest at the time it's completed. I can't put this off much longer.

A:
It is not the intended purpose of the "Nice Smile" column to refer patients to individual dentists for treatment, but rather, it provides information so that patients can make sound decisions regarding their oral health. However, I can make a couple of suggestions that may help you follow the path towards improved dental health. Some of the things I will mention may not apply to your situation, and some of the suggestions will perhaps challenge you to think about your oral health differently. Either way, our goal with the Nice Smile Column is to put you in control of your health, and many people have more control than they realize.

1. Preventative dental care costs about 70 cents/day. This would include a regular cleaning, examination, and x-rays. This will help insure that healthy teeth stay healthy. This is within reach to nearly everyone with or without insurance.
2. Closely follow the home care and diet recommendations of your dentist. These recommendations are designed to reduce your dental care needs.
3. Look carefully at spending priorities and consider what you can go without for a little while so that those funds can be directed towards your health. For example, cable TV, cell phone, smoking, and eating out, are all tapping into what may be a limited budget. By reallocating resources, you can begin working to address your health needs.
4. Consider financing your dental treatment using a home equity loan, or other short term loan. Most people consider having a car as a necessity. If having your teeth is a necessity, then obtaining a loan as when buying a car, would not be unreasonable. Many dentists also offer a 3-12 month no-interest financing plan through third party lenders.
5. Consider having your dental work completed by a dental student at the U of M (Ann Arbor) or the University of Detroit/Mercy (Detroit). Your treatment will take longer to complete, but will cost less.
6. You can apply for Donated Dental Services by calling (800)850-5913. There is limited enrollment to this program with strict eligibility requirements.
7. Build a long term relationship with a dentist so that when a true hardship arises you are more likely to get some charitable help. As a dentist, there is nothing more frustrating than someone looking to be financially bailed out of dental trouble after they have totally neglected their dental health for many years. However, most dentists will help out those patients that have a true need and have made an effort by keeping up with prevention (item #1 above), scheduled appointments, and have followed preventative care and diet recommendations.

The cost of providing dental care to patients' correlates to the patient's cost of receiving that care. Quality care cannot be provided at a discount unless the care is being provided charitably. Unfortunately, there are so many people that express hardships; dentists have a very difficult time weighing each individual situation as to whether it is a true hardship, or an uninformed patient making poor priority choices. Hopefully, the suggestions above will help point you in the right direction.

Career in Dentistry
Q: I am interested in a career in dentistry. Can you give me some tips?

A: Dentistry, and its specialties will continue to fair well in the future. In fact, there will most likely be a shortage of dentists in the next ten years. That's the good news, I think. The bad news is that getting into dental school is very competitive. Over 1000 applicants applied to the University of Detroit Mercy last year for a class of approximately 75 students. The grade point average when applying should be 3.5 or above. Also, community involvement, observation time in a dentist's office, and good scores on the Dental Admissions Tests (DAT), will weigh heavily on your application. Your admissions interview is also very important and should be taken seriously. The profession of dentistry, starting at the dental schools, is very interested in the character and ethics of those entering the profession, therefore anything that you can offer the admissions office that says something about your character and ethics would be very helpful.

Once you are accepted the next battle is the cost. Most dentists graduate with student loan debts over $120,000 and then there is the little issue of setting up an office which is going to be another $300,000 even for the smallest of offices. All these expenses come before you have even seen a patient! Since the loans for these expenses are often uncollateralized, interest rates will usually be higher. If you purchase an existing practice with proven cash flow, you are going to spend around $250,000 to $600,000, depending on the practice revenues over the last few years. Taking over a practice from a retiring dentist (the greatest dentist on earth) is very hard work. You are the "new" doc and there is no guarantee that the patients will stay with you once you purchase the practice. You are also become an employer, and you must be as committed to your employee's success as you are to your own. What I am saying, is that although financial success in dentistry is common, you must be the type of person that can accept delayed gratification. You must also be a "people person," and you must make a great first impression. Your success in dentistry will build strongly on your ability to communicate effectively.

This all may seem very hard, if not impossible. There are four things that will make all go easier, while allowing you enjoyment in this profession. These things are honesty, morals, ethics, and compassion. Don't get misled into believing that dentistry is one of those professions that allows you to get rich quick. It is hard work, and it your success will be based not only on your skills, but also your character.

For the most part, dentists do not view other dentists as competition. Therefore, you will always find a mentor in the dental community. Never be too proud to accept the helping hand from an experienced practitioner. That being said, I hope to see you as a colleague in the future!