Take Care of Your Teeth and Mouth

Surprising as it may seem, many people are unaware that dental disease is just like any other infection caused by bacteria. It is a disease that can spread easily, is transferred from person to person, and worst of all, can grow on things like toothbrushes. Once you realize that dental disease is this kind of infection, you understand how very simple steps can be used to control it.
In the nineteenth century, progressive medical surgeons begged peers to wash their hands so as to prevent the spread of infection. Today I beg patients to clean their mouths and their toothbrushes to control the spread of tooth and gum disease between family members. Today we have become more aware of the delicate balance that exists between the bacteria that help and protect us and the bacteria that cause infection. Overuse of antibiotics showed us that if protective bacteria were removed, overgrowth by harmful ones often followed, and the same reactions can be seen when we look at mouth bacteria.

Medical tourism in Iran

Dental Implant in Iran

Hollywood Smile in Iran


Bacteria that live on teeth can grow only when attached to a hard, non-shedding surface. Some kinds of tooth bacteria are harmful, whereas others are good for our dental health. In fact, it appears that teeth need a barrier of healthy protective bacteria to stop harmful ones from damaging the tooth surface. The balance between good and bad bacteria is important for dental health, and it is also important to know that this balance can change. People are often surprised to learn that they can lose healthy bacteria following an abrasive dental cleaning, after taking a course of antibiotics, or when the mouth becomes dry or acidic for long periods of time. During times of change, it is possible for a new type of bacteria to infect your mouth and suddenly cause damage to your teeth and dental health.

Tooth bacteria rarely exist in a baby’s mouth before the presence of a tooth. Therefore, the origin of these bacteria is necessarily someone else’s tooth. DNA studies have illustrated that a parent, usually the mother, is most often the person who passes tooth bacteria from her mouth to the baby’s mouth when his or her first tooth erupts.1 Most people imagine a genetic link or something in mother’s milk that passes on dental disease. The truth is that dental disease is transferred directly to a child’s new tooth, often during a loving cuddle or a kiss.
Most often, parents and caregivers share their mouth germs with their children (vertical transmission),2 but it is also possible for mouth germs to spread between siblings or from spouse to spouse (horizontal transmission).3 Parents should also be aware that children born by caesarean section appear to be infected by mouth germs earlier—possibly because they lack some kind of protection—than do vaginally delivered infants.4
Bacteria travel to the new baby tooth most often in a droplet of saliva. The bacteria can transfer during a kiss, from a drop of saliva on spoons or pacifiers, or from food shared with a baby. I would never suggest that parents stop kissing their baby or worry about sharing food. Think about this: If the bacteria do not come from your mouth, they will be transferred from the mouth of someone else who comes into contact with your child. Since this bacteria transfer cannot be stopped, it makes more sense to control the kind of bacteria passed to children.
Obviously, you want a baby to be infected with healthy, dentally protective bacteria rather than aggressive, cavity-forming ones.5 The fact is that once a particular kind of bacteria reaches a baby’s first tooth, this bacteria will then colonize or spread to the other baby teeth as they erupt. It has also been shown that whenever there are many harmful bacteria in a parent’s mouth, the chances that they will transfer to the child are greater.6 It has also been shown that the first kind of bacteria to infect the biting surfaces of molar teeth usually become the dominant strain in the mouth, because the grooves of these teeth become reservoirs of bacteria for the mouth. Changing the kind of bacteria in a child’s mouth after molar teeth have erupted becomes more difficult. This fact can also be used to a parent’s advantage—as you will see later on. To give children the best advantage, make sure that healthy bacteria are established in their mouths before the molar teeth erupt. This simple change can provide your child with many years of dental protection.
Research during the 1980s illustrated how bacteria were transferred between family members and from mouth to mouth. A simple and successful method of controlling this transmission was found just a few years later. For twenty years we have known how to reduce both the inheritance of bad tooth bacteria and the chance of a parent infecting their child with the bacteria that cause cavities. Parents with bad teeth can get rid of aggressive and harmful bacteria from their mouths, and even without traditional dental treatment. You may be shocked to discover that it is possible to remove harmful bacteria even if you still have cavities or cannot go to the dentist, for whatever reason. When the bad bacteria are gone from your mouth, protective ones will take their place.7
From a parent’s point of view, it is important to know that the earlier a child is infected with harmful mouth bacteria, the greater the child’s risk for having cavities later in life. As mentioned earlier, changing the kind of bacteria in your mouth becomes more difficult when molar grooves have become reservoirs of mouth bacteria.8 Baby molar teeth erupt during the second year of life. Consistent with this fact are the results of studies showing that children who are infected with harmful bacteria by age two have the most cavities at age four.9 When parents have healthy mouths during the first year of their baby’s life, their children will have less chance of infection from harmful bacteria and a better chance for oral health. Studies have also shown that at five years of age, children from parents with healthy mouths have 70 to 80 percent less chance of developing cavities, and the benefits may last into adulthood.

Preventing the passage of harmful germs to the next generation may be the most promising method of preventing cavities in children’s teeth. If this is the first time you have heard about this kind of bacterial transfer, it will be natural for you to wonder why there has been no media attention and no national education on the topic.
For many years, dental associations in Europe and Scandinavia have been promoting such control of infant mouth bacteria as a means of improving oral health. Recently, a few state health organizations in the United States have begun to educate health professionals about oral bacteria transmission. Unfortunately, some of their recommendations seem unrealistic.
In 2007, for instance, the New York State Department of Health published a guide for oral care during pregnancy and early childhood.11 The department’s advice for preventing harmful bacterial contamination between mothers and infants and between siblings is that families should avoid saliva-sharing activities. Basically, they recommend that a mother not kiss her baby and that children not be allowed to share their toys. As a mother of five, I look at these recommendations and shake my head, wondering how anyone could even think of suggesting that a mother not kiss or share meals with her baby, or how anyone could recommend that toddlers not be allowed to play with one another’s toys.

Even if a mother avoids kissing her baby, inevitably someone else will infect the child. Most parents would prefer to take ownership of this duty and prepare to pass healthy bacteria from their own mouths to their child. In daycare centers there are risks of contamination among children and also from caretakers. A study from a daycare center in Brazil suggests that horizontal transmission occurred among children in such situations.12 Parents should understand these risks if their infant is in daycare and take some simple steps (as outlined in chapter 14) to keep their baby’s teeth healthy and safe.
Mouth Chemistry

Mouth chemistry is affected by hormonal factors, poor diet, dehydration, and medications, especially those that change hormone levels, affect diuretic or liquid balance, or have the side effect of dry mouth. Sometimes changes in saliva flow and mouth chemistry occur so slowly that you can be unaware of your increased risk for cavities until problems arise.
Women’s mouth chemistry in particular is volatile, and changes that make the mouth more acidic will have devastating effects on their teeth. A number of life situations can influence and cause the chemistry of the mouth to deteriorate. For example, new mothers who have enjoyed perfect teeth all their lives may be shocked to find cavities develop during their pregnancy. Sometimes the damage is seen as loose fillings, bleeding gums, or sensitive teeth. Hormones trigger a change in a pregnant woman’s saliva, altering its quality and limiting its ability to provide natural tooth protection. These changes can occur at any time during a pregnancy, but the most risk for acidic damage to teeth occurs during the last trimester. (See chapter 13 for more details about changes in a woman’s mouth chemistry during pregnancy.)
Other situations, many beyond your control, can suddenly increase your risk of dental damage without warning. One of the best ways to minimize the chance of cavities is to strengthen your teeth in advance of any problems and to protect teeth daily as much as possible. The following is a list of circumstances that can change your mouth chemistry by making saliva more acidic or by drying the mouth and, consequently, elevating the risk of developing cavities and other dental problems:
Nasal congestion from seasonal allergies, asthma, or sinus infections
Hormonal changes (including pregnancy, adolescence, and menopause)
Medications (including Ritalin)

Illness with fever or nasal congestion (even a simple cold or the flu)
Mouth breathing (athletics, wearing dental braces)
A chronic or acutely stressful situation, such as a death or crisis in the family, or business stress
Duties that involve constant talking, such as lecturing, teaching, or stage performance
Gastric acid reflux
Chemotherapy or long-term illness
Poor diet, with lack of minerals and vitamins
Work in situations where oxygen changes (divers, astronauts)
A feeding or breathing tube in hospitalized patients

The idea of controlling mouth acidity may sound daunting at this time, but you will soon discover how simple routines can give teeth the protection necessary for dental health. Balancing mouth chemistry is relatively easy and will help you avoid dental problems.


Dental Attitudes

A number of years ago I attended a continuing education course whose featured speaker was a world-renowned cosmetic dentist. The dentist was extremely talented at fixing and re-creating natural-looking teeth. Instead of cutting down a tooth and sending an impression to a laboratory to make a cover or crown for it, this dentist left the original damaged or stained part in place and built a repair on top of it, directly in the mouth. Within an hour, he could mix porcelain-like pastes together and sculpture a new creation, adding shades of color to magically turn something broken and ugly into a perfect and natural-looking tooth.
The introduction to his course was a slide show of before and after pictures. We looked at patients old and young whose teeth were damaged, stained, and broken. Many of their teeth resembled little brown stumps in great need of a dramatic makeover. Cosmetic dentists from all over the world attended this course to learn about this particular repair method, materials, and techniques.


Medical tourism in Iran

Dental Implant in Iran

I raised my hand to ask a question. “Excuse me, but why do these patients have so much tooth damage?”
I felt the eyes of everyone in the audience stare at me in disbelief, as if I had asked the question in a foreign language. Why was I interrupting and wasting time? This was not the reason so many people had gathered together for the weekend. The dentist had no answer as to why his patients had so much erosion and damage to their teeth, so the lecture moved on.
In the years since then the speaker has become my friend. He has a great deal of interest in the prevention of dental disease, erosion, and tooth wear. In his office, patients are regularly interviewed to discover the cause of their dental damage and, even before his makeover treatments, they’re counseled on how to prevent similar problems from occurring in the future. Today this dentist is a strong proponent of xylitol and the preventive program I recommend. He understands that although people come to him simply wanting good-looking white teeth, he needs to give them not only a beautiful new smile but also a way to keep it healthy and prevent future relapse. Without making some kind of change, the same problems that cause the initial tooth damage will cause the new “makeover” treatments to fail—often in less than three or four years.

Dentists and Prevention

Since ancient times, dentists have been viewed with trust and dignity. In Egyptian tombs, hieroglyphs have been uncovered showing an eye over a tusk. They date back to the fifth dynasty, indicating that even then, dentists were honored for their treatment of teeth. Today the profession continues to be made up of caring people who diligently follow the systems and teachings they learned at dental school. As their careers unfold, dentists expand their knowledge by attending seminars or courses and by reading books or professional journals.
The problem is that once a dentist graduates, he or she is usually too busy dealing with the daily workload of private practice to hunt for ideas that have not been presented at dental school, in journals, or during continuing education programs. In the United States, the majority of dentists have been trained to believe that prevention is flossing, diet control, regular dental cleanings, fluoride in the water, and oral examinations. Many dentists are unaware of other methods that effectively stop dental problems. Most believe it is impossible to halt dental disease.
In dental school, for example, we never discussed such variables as acidic saliva or mentioned tooth damage that occurs directly from acidic foods or drinks in the mouth. Not one of us ever thought to inquire whether foods or beverages like lemon juice or soda created acidic problems for teeth. We were never shown how to test the acidity of saliva or told about how it varies from person to person, from day to day, and even from situation to situation. Only one “fact” was hammered into our brains: Sugar causes cavities!
Dental training taught us to fear sugar and any food containing sugar or carbohydrates. Good dentists made patients worry about most of the foods in their home pantry: fruits (too many sugars); potatoes (too much starch); cereals, breads, potato chips, and

crackers (too much of both); and of course candy, cookies, cakes, chocolates, and other desserts. Dr. R. M. Stephan’s graphs from the 1940s alerted us to the danger of snacking: a colorful zigzag line that never reached a level of safety because there was no time for recovery between the “sugar attacks.”۱ Few dental students have discussed food interactions, the benefits of tooth-protective ingredients in a meal, or how to reduce acidity with tooth-friendly foods.
The majority of dentists think that patients should control their sugar and starch intake and floss better if they wish to improve their oral health. Unfortunately, you can diligently follow these procedures and still experience dental disease. Consequently, dentists have become discouraged about prevention, and most are resigned to a career of fixing their patients’ ongoing dental problems.
A New Type of Dentistry

The knowledge of how to prevent cavities and gum disease dates back to the 1960s, yet even today many people think it is difficult, perhaps impossible, to have healthy teeth. Children and adults with bad teeth often do not know the reasons for their problems. Too many people subscribe to an antiquated notion that worn teeth, chipped enamel, sensitivity, or bleeding gums are inevitable, or at the very least are a part of the aging process. Some people blame their troubles on insufficient flossing or too few cleaning appointments. People are aghast if I tell them it is possible to have strong, clean, bright teeth and healthy gums without regular dental cleanings and even without flossing.
Dentists will always be necessary to fix broken teeth and make cosmetic changes to beautify a smile, but when you have finished this book, you will understand why dentists cannot be the ones to prevent your cavities or stop dental disease in your mouth. Weak, soft, or old teeth are frequently given as excuses for dental problems, but these descriptions do not explain why you have tooth damage. Finding out why you have cavities or bad teeth is an important step toward preventing these problems and stopping the same damage from recurring in the future.
Imagine that water is damaging a floor in your home. Before you can fix your floor, you must find out where the water is coming from. If you cannot find the cause, no matter how many floor repairs you make, more water damage will occur. The only way to fix your problem is to find the source of the water, stop it, and then repair the damage. It is the same with your teeth. Where is the damage coming from? Until you find the source of your tooth problems, repairs will need to be done over and over, possibly getting more expensive and complicated each time. To put an end to soft, weak, stained, brittle, or sensitive teeth, you must first find out what is causing the damage.
Dentists have known for years that damaged enamel can be hardened back to total health with a simple repair process that occurs naturally in the mouth.2 Under certain conditions, minerals from saliva can flow into teeth to strengthen them and in this way can even repair a cavity and prevent the need for a filling.3 In 1999 a small group of dentists founded the World Congress of Minimally Invasive Dentistry to focus on prevention of dental disease and to promote techniques that preserve teeth and limit treatments that cut or damage them. These dentists believe in preventing dental disease by intercepting its progress with the least destruction of tooth tissue possible. Many of them recommend xylitol and explain natural tooth healing to their patients. In 2000 an international review paper described how dentists can use a natural repair system to limit the need for dental fillings and as a result practice minimally invasive or “minimal intervention” dentistry.4
A list of the world congress’s members can be found at its website: www.wcmidentistry.com.5 The Federation of Dentistry International also endorses a preventive approach to preserve teeth and allow natural healing to occur.6 In addition, many pediatric dentists are familiar with a minimalist approach to treatment called atraumatic restorative treatment.
In the summer of 2006, the New York State Dental Journal published an editorial suggesting that dentists should educate patients about the “biological price” of dental treatment, particularly when other options, including an option of no treatment at all, exist. This was one of the first times I had seen anyone voice a concern about dental treatments and offer the idea that “no treatment” may be a benefit to the patient. Many dentists, like me, worry about the health impact of materials used for fillings, especially mercury-containing silver or white plastic compounds that may leach destructive ingredients. Why place a filling if there are natural and possibly safer options? The respected author of the editorial appears to believe that there should be greater emphasis on communication in the dental office and that this exchange of information will, in the long run, help dentists retain

public confidence.7 I wholeheartedly agree with this concept and hope that dentists will promote more in-office dental conversations with patients about treatment choices for their dental health.
Today oral-care and dental-material companies orchestrate most American education programs for dentists. At a recent conference I was amazed to hear the worldwide director for one such company say that oral disease is not preventable. Her company educates dentists yet benefits from continued dental disease, so ask yourself: Would this be the most likely source for information about simple techniques that eradicate dental disease or for inexpensive, non-patentable methods that patients could use to maintain their own teeth in total dental health for life?
The subject of preventing dental disease has appeared to be absent from most major dental meetings, journals, and continuing education courses during the past twenty years. Since becoming a resident of the United States, I have searched for courses about mouth acidity, xylitol, or the process of natural tooth repair called remineralization. What I have found, instead, are courses on practice management, pharmacology, emergencies in the office, and many other sides of dentistry that fix and repair teeth. In 2001, however, I noticed that the National Institutes of Health, headquartered in Bethesda, Maryland, was looking at how dentists diagnose and manage dental disease and how to prevent cavities.8 Naturally, I traveled to the meeting with excitement, and I was not disappointed, finding the information fascinating as well as helpful.

One subject covered at that conference was the use of a device that dentists call an explorer. The sharp-pointed instrument has been a favorite dental tool for decades. The dentist holds the explorer in one hand and a small mouth-mirror in the other. Together, the explorer and the mirror allow the dentist to examine and feel the surface of your teeth, finding softened areas on their surfaces or any cavities or tooth decay that may have developed.
In the 1950s, it was common for dentists to force the instrument’s sharp point against the surface of your tooth in their search for so-called sticky spots or potential cavities. Dental students were taught to push the point into any suspicious area and see if it could break the surface of the tooth, which would indicate this area needed a filling. By 1966, studies showed that softened areas on teeth could completely heal themselves with correct care, and that a cavity will disappear when minerals are replaced in it. Pushing a sharp point into a weakened area on a tooth reduced the chance of such a repair.9
Natural tooth enamel can rebuild itself and heal a soft spot, and this occurs quickly if the surface of the tooth remains intact. The repair process becomes more complicated and difficult, even impossible, however, if the surface is broken.10 A study published in 1992 in the journal Caries Research reported on 100 teeth that had been examined with the explorer, been found to have sticky spots, and been extracted. The teeth were then cut into pieces and examined under a microscope to see whether the diagnosis of a cavity was accurate. Only 24 percent of the teeth with sticky spots had real disease and decay. The study showed how unreliable the explorer technique is for finding a cavity.11
Today any dentist who believes in natural repair of teeth would never forcibly push an explorer into a tooth surface. He or she would trail a blunted instrument over the tooth surfaces to check for roughened areas. If any were found, the dentist would suggest ways to harden and repair these soft spots naturally, remineralizing the softened areas until they went away and left a healthy and strong tooth.12
Obviously, pushing the explorer into the tooth can increase the chance of forming a cavity and may prevent a repair that otherwise would have been possible. The explorer can give a false reading, especially if the point is pushed into grooves on the biting surfaces of teeth. A few dentists remain determined to use the explorer in the time-honored way, claiming it is efficient standard care that is well accepted by the profession, insurance companies, and patients. There are dentists both for and against the “strong” use of an explorer on your teeth. Which kind of dental examination would you prefer?


Another subject for debate is when a tooth requires a filling. Until recently, it was your dentist’s judgment call. Of course, if you have lost a chunk out of your tooth or if it is giving you pain, the decision may be obvious. The dilemma presents itself when the cavity is in its beginning stages,14 a scenario that occurs regularly in dental offices every day in America.
One dentist may suggest a filling or a sealant to fix a tooth that has a softened or weakened area, usually visible on an X-ray. When a tooth with porosity or lost minerals or softened parts is X-rayed, the X-rays are able to travel through the empty or liquid-filled spaces more easily than through a harder, healthy tooth. X-rays of a hard or dense tooth bounce off the surface and make the image lighter or brighter in the film. The weakened tooth areas will be a dark or even black shadow against the brighter surface on the resulting film.
One dentist may see a shadow and suggest a filling. An equally qualified dentist may take a sequence of X-rays at regular intervals to see if the tooth is regaining its strength or weakening, explaining to the patient that he or she needs to go home and use a program that will strengthen and rebuild the softened tooth. The second dentist is giving the patient a chance to repair the softened area with natural healing so as to avoid a filling.
A weakened tooth can be rebuilt to total strength in a matter of months. With correct home rinsing and the use of xylitol (which are discussed in detail in chapters 13 and 14), a patient may be able to fix this kind of defect and never need a filling. If preventive treatments are not followed, however, the cavity could potentially become worse and spread into the live area deep inside the tooth. If that happens, the consequences would be more extensive treatment and possible damage to the central nerves of the tooth. Which decision is correct from an ethical standpoint?
Some dentists do not believe in natural tooth repairs because they have never seen a tooth rebuild itself. Without guidance, how would they become confident in the outcome? Dentists in a group practice may not see the same patient over time. An older dentist may have experience, but a young dentist may be solely dependent on his or her schooling. Consequently, the decision about whether to fill your tooth may be influenced by the age of your dentist, whether he or she has attended preventive lectures, or if he or she has interacted with other professionals knowledgeable about the natural rebuilding of teeth.
Perhaps your fillings could have been avoided. Research clearly shows disagreement among dentists about when a cavity requires a filling. A different study conducted in 1992 showed that the most likely error dentists make is filling a sound tooth, which happens when dentists look at X-rays and use traditional methods of diagnosis. They often decide to fill teeth that actually do not need filling.15
Fortunately, new technology is helping dentists make decisions more accurately, and with public demand, more people may be given preventive options.


There are many good reasons to avoid fillings and to prevent gum disease at all costs. Over the past twenty years, a number of dentists have been so concerned about silver filling materials that they have removed them for the sake of their patients’ health. Silver fillings are a mixture (an amalgamation) of metals that include almost 50 percent mercury. Mercury is a liquid metal used to bind the other dry metals together, just like an egg or oil is used in a cake mix. Like steam, however, mercury can vaporize and is toxic to humans when it is inhaled, ingested, or absorbed through the skin.
Today dentists no longer handle mercury or mix silver fillings directly. The ingredients are in capsules that are mixed automatically without contact with the skin. In many countries, organizations are trying to limit the use of mercury in health care and other industries.16
The argument in favor of silver fillings is that they have a long history in dentistry. The American Dental Association (ADA) claims that “the best and latest available scientific evidence indicates it [amalgam] is safe.”۱۷ Records indicate that about 70,000 kilograms of mercury are used in more than 100 million dental fillings each year. Most dentists say they prefer amalgam over white filling materials for molar teeth.
Despite this endorsement, many people distrust silver fillings. In Sweden, Denmark, Germany, and Austria it is illegal to use silver fillings; a dentist can go to jail for using them.18 It is now illegal in California to put silver fillings in the mouth of a pregnant woman because mercury can transport across the placenta and also enter mother’s milk. In every dental office, old fillings or extra filling material must be placed in a special container and disposed of as toxic hazardous waste. If fillings break down in the mouth, it is easy for patients to eat or swallow pieces of them by mistake. Crumbling and failed fillings appear in acidic mouths, and some people have silver fillings replaced frequently throughout their lifetime, exposing themselves to mercury poisoning at each repair.
Statistics show that more than half the silver amalgam fillings put into teeth eventually need repair. The average life span of an amalgam was found to be 12.8 years, although that of a white filling was even less, only 7.8 years.19 Consider a single tooth and how many times one filling may be repaired over a lifetime. Imagine if a filling is originally needed in a molar tooth at the age of five or six. How many fillings will four of these molars need throughout a person’s life? Imagine a mouth full of fillings and the possible exposure to mercury these may cause. In an acidic, diseased mouth, fillings deteriorate quickly and may need replacement more often, even every few years, potentially exposing you to even more mercury and metal harm.
Drilling out old amalgam must be regarded as a serious procedure because high amounts of mercury vapor are released in the process. Extreme care should be taken to perform the procedure safely and with adequate protection, ideally with strong suction and a barrier to stop removed pieces or amalgam dust from being inhaled by the patient. The International Academy of Oral Medicine and Toxicology has established safety guidelines. Vapors from the new filling are equally problematic, and no excess filling should be left in the mouth in case it is accidentally ingested. These particles may be dangerous to health, especially for young or growing children. Your dentist should provide you with an alternative source of air during the procedure to keep you from inhaling mercury vapor.
If you prevent mouth acidity from damaging your silver fillings, they can last for decades, even for your whole life. As a geriatric dentist, I often saw fillings that had been placed in childhood still strong after sixty or more years. On the other hand, in an acidic and diseased mouth, fillings I personally placed with maximum care were leaking and failed within two years, not because of the materials but because of acid erosion around the filling, causing the enamel holding the filling to flake away.
If you have a healthy mouth, silver fillings can remain stable. Personally, I consider it safer to leave them in place rather than

rushing to change them to another material. I would encourage everyone to protect and strengthen their enamel, because at this time there do not seem to be any perfect alternatives. Even white filling materials have safety questions, and few studies have been conducted to evaluate them. In addition, plaque bacteria appear to stick more readily to white fillings than to silver or gold ones. Gold or porcelain may be the best choice for molar teeth, but be aware that if gold and silver fillings are both present in an acidic mouth, they can mimic the chemistry of a battery and even create an electrical current.
Dental materials are changing all the time, so if you need a filling, discuss the topic with a trusted dentist and learn the advantages and disadvantages of the dental materials he or she suggests. The Internet is a good resource, but check the source of your information, and remember, the ADA has supported silver fillings since the 1800s. Ask about the safest filling materials and which ones are the most durable. If your dentist talks about watching a questionable tooth, remember how much healthier it is to have perfect teeth and find out if natural remineralization is an option.
New Techniques in Dentistry

Special equipment involving ultrasonic depth testing has recently been developed to help measure the strength of a tooth and display it in picture form on a computer screen.20 It is now easier for a dentist to detect weakness in your tooth in time to warn you of an impending cavity. With that knowledge you could go home and rebuild your tooth using the repair process I describe in chapter 13. It is relatively easy to monitor the effects that products have on teeth because changes can be observed and measured. For example, if a product claims to strengthen or repair your teeth, you may notice the difference yourself, but we now have the technology to measure tooth strength and confirm if such claims are true. 21
Today it is possible to take a digital picture or make a videotape of a tooth and view a cavity healing and shrinking in size. You can literally watch tooth damage disappear as minerals go into a tooth and repair it.22 Your progress and improvement could be evaluated and measured at regular intervals with this kind of monitoring equipment.
To detect areas of softening not yet visible to the eye, special lights with attached computer systems have been developed. One

method uses a Digital Imaging Fiber-Optic Trans-Illumination (www.difoti.com) and another, the DIAGNOdent laser, lights up bacteria by-products in a tooth (www.kavousa.com). There is also a fluorescent light, called the InspektorPro, which shows the relative strength of a tooth (www.omniipharma.com). The light causes a pattern that can be seen on a computer screen, with different colors corresponding to various degrees of tooth hardness.23 This kind of light can therefore be used to show if, and by how much, a tooth has hardened up after a patient has used tooth-restoring measures. This method will eliminate the guesswork and help patients, and dentists, see that preventive treatments are working. If your dentist informs you that a tooth or teeth are starting to soften, you would then have time to prevent a cavity by using healing methods in a dental office or at home before the damage becomes irreversible. You should be visiting the dentist for a screening to help you prevent cavities rather than for treatments and fillings.24
Many people find this idea exciting, especially if the result is a lifetime of perfect teeth. Some dentists, on the other hand, do not think a cavity is a big deal; they may lack confidence in tooth repair and may have never seen a tooth rebuild itself. These dentists may worry that if a patient does not comply well enough, a small cavity could progress and become bigger. A home repair method depends on you, not the professional skill of the dentist. Such concerns may be reasons why dentists have ignored natural repair, choosing fillings instead. I believe that patients should be given the chance to choose between natural repair to heal a tooth and traditional repair with a filling.
Dentists as Evaluators and Fitness Trainers

Patients certainly expect dentists to be concerned about helping them avoid disease, infection, cavities, and tooth loss. On the other hand, I have found that some people worry that their dentist will be upset about losing business if healthy mouths prevail. The dentists I know are delighted to find an effective way to protect patients from unnecessary treatments. I frequently talk to hygienists and dentists about my method of dental care, and although some are skeptical at first, they are always enthusiastic when they discover how effective this system is for preventing dental disease.

Patients should seek out dental professionals who believe in prevention and who will help them avoid treatments. I hope that dentists will be viewed more as dental evaluators who use their expertise to alert patients in advance of a cavity, so that patients could take steps to avoid the need for fillings or treatments. Dental care would be more akin to a visit to the gym—hygienists and dentists would be mouth fitness trainers, measuring your risk for cavities and offering ways to strengthen and protect your teeth.25 You may have decided to select your current dentist because he or she accepts your insurance plan, but in the future you may think about selecting someone who believes in remineralizing teeth and who is known for a caring and effective approach to preventing dental disease.
Imagine if your dentist could alert you that your teeth were about to soften and give you time to prevent cavities in them with healing home-treatment methods, before the need for fillings. If you kept regular visits they would be for screening and to help you prevent cavities so that you would never again need to go to the dentist for extractions, root canals, or fillings.26
Dentists who help their patients enjoy healthier teeth see positive changes in their offices. Dentists who help patients take control of their dental health develop new relationships, especially as their patients become confident about dental visits. The number of broken appointments is reduced, and although less treatment may be done, more patients can be seen each day. Furthermore, happy patients refer many others.
The best news is how simple it is to prevent dental problems with correct home care. By using the system I describe in part VI, you will find that by yourself you can begin to successfully avoid cavities and many annoying dental problems. You can begin the preventive program whenever you choose, and because it is simple and convenient, you will most likely find that it quickly becomes an enjoyable and rewarding daily routine that you will use forever.


a day in the life of dentist

How do dentists start their days?

Each morning, dentists get the office ready for patients. Dr. Fong plans the day with the office workers. They check if each room has enough toothbrushes and napkin bibs. They make sure the tools they need are clean.

a day in the life of dentist

What do dentists wear?

Dentists wear clothing that keeps them clean. Dr. Fong puts on gloves and a white coat. She wears a mask and glasses while looking in a patient’s mouth. Wearing this clothing keeps Dr. Fong from spreading germs.

What do dentists wear?


Medical tourism in Iran

Dental Implant in Iran

Who helps dentists?

Dentists have many helpers. Dr. Fong’s office manager greets patients. She also makes appointments and writes bills.

Who helps dentists?

Hygienists clean teeth. Assistants help dentists work with patients. Everyone works together to make the office run.

Who helps dentists?

What do dentists eat for lunch?

Dentists try to eat healthy foods like fruits and vegetables. Dentists know these foods help keep their teeth strong. Dr. Fong eats an apple with her lunch. She reads a book about new ways to fix teeth. After lunch, she brushes her teeth.

What do dentists eat for lunch?

What happens at a checkup?

Checkups help dentists make sure a patient’s mouth is healthy. Dr. Fong takes x-rays. She counts the patient’s teeth and looks for tooth decay. She checks his gums for disease. Dr. Fong writes a report about each tooth. Sometimes she will put flouride on teeth to help prevent cavities.

What happens at a checkup?

What happens in a dentist’s lab?

Labs are workrooms for dentists. Dentists can make models of teeth in their labs.

Dr. Fong mixes plaster. She pours it into a mold shaped like her patient’s teeth. The plaster hardens into a model. Dr. Fong uses the model to show the patient how she can repair his teeth.

What happens in a dentist’s lab?

What tools do dentists use?

Dentists use many tools to keep teeth healthy. Dr. Fong uses a bright light and mirror to look in the patient’s mouth. A small drill helps Dr. Fong repair a cavity. The assistant sucks out water and saliva with a vacuum straw. They repair the tooth together.

What tools do dentists use?

Why do people need to visit the dentist?

Dentists help people take care of their mouths. Dr. Fong explains to a patient how sugar and germs damage teeth. She teaches him how to brush and use floss. Dr. Fong goes home knowing her patients have healthy teeth.

X-ray machine and x-rays

Where You Go for Dental Care

With the exception of major surgeryto correct a cleft palate or repair facial bones broken in an accident, for examplethe choice of where you get dental care has less to do with the type of procedure and more with specific conditions you might have. Almost every dental procedure (except major surgery) can be and is performed in any of the three main types of settingsthe office, the ambulatory care (outpatient, same-day surgery) center and the hospital. Before we consider issues involved in evaluating each setting, let’s look at some of the conditions that might affect where you get your dental care.
ò Level of anxiety. People who have intense dental anxiety may be referred to ambulatory care centers or hospitals to have procedures done under sedation or general anesthesia. In addition, a few hospitals, such as the Mount Sinai Medical Center in New York, have created dental phobia clinics to provide both dental care and counseling to decrease the fear.
ò Disability. Physically challenged patients, especially those with cerebral palsy or other diseases that affect muscle control, and mentally challenged patients need careful monitoring and perhaps sedation during dental care; even basic procedures such as restorations (fillings) are likely to be performed in an ambulatory care center if available or in a hospital.

Medical condition. In medical parlance, people with preexisting medical conditions that could affect the outcome of a procedure are referred to as medically compromised. These include individuals with chronic illnesses such as heart disease, lung disease, high blood pressure and cirrhosis and other liver diseases, as well as people with active infectious diseases such as tuberculosis or anyone undergoing radiation therapy for cancer. Such patients often require laboratory tests and evaluations and close monitoring by their physicians when dental procedures must be done. Often their care is provided in hospitals.


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ò Dental condition. People who need extensive dental care in one visit will likely be referred to an ambulatory center or hospital. Among these circumstances are a toddler with nursing bottle cavities (multiple cavities in front teeth from sucking on a bottle during sleep); a patient with facial injuries needing a team of specialists to surgically correct them; or an adult who needs several root canal procedures (to remove the root and eliminate infection) done in one sitting because he or she cannot schedule several routine office appointments to carry out the therapy.
If, on the other hand, you’re healthy, you’ll probably receive your care in the office if you need any of the following procedures:
ò Restorations, both fillings and artificial crowns
ò Extractionsi.e., removal of one or more teeth
ò Root canal therapy that removes the root, cleans the canal and prepares the remaining structure for a crown
ò Orthodontic therapy to straighten teeth
ò Periodontic therapy to eliminate gum disease and repair damage to gum and bone from bacteria
ò Denture preparation and fittings
Just what can you expect when you get care in a dental office? And what potential dental hazards should you know about?
Your Dentist’s Office

Dentistry remains overwhelmingly office-based. You’re likely to find these offices in medical/professional buildings, health maintenance organization clinics, shopping centers and malls and, of course, in self-contained, stand-alone offices. Whether the office is in a converted house or an ultramodern building, its general layout is likely to be similar. During your get-acquainted visit, take a moment to familiarize yourself with the surroundings. This will help you put into context the various aspects of office safety we discuss later in this chapter.
The Layout
As you look around, you will probably find the following areas:
ò Patient waiting area
ò One or more patient treatment areas, known as operatories
ò Front office/medical records/billing room
ò Laboratory for sterilization of instruments and adjustment of dental appliances such as dentures and partial bridges
ò X-ray development area or darkroom
ò Dentist’s private office/consultation room
The greater the number of dentists in the practice, the greater the likelihood that you will find all these rooms.
Within a typical operatory may be various cabinets and drawers for supplies, an x-ray machine, an electrically controlled reclining chair for the patient and wheeled chair(s) for the dentist/hygienist, two sinks, an adjustable overhead light, a saliva ejector (a small suction pump and hose with a disposable tip), an air compressor and hoses that power the handpiece with its detachable heads and tips, and the instrument tray. You may also see an ultrasonic cleaning machine for removing tartar and plaque and a video camera and monitor for viewing your teeth and gums.
All rooms should be clean and uncluttered. Patient areas should be brightly lit. Furnishings and equipment should not be worn or broken. Look for an environment that calms you and contributes to your physical and emotional comfort. The availability of patient education brochures, videos and/or health and fitness magazines is one indicator of a dentist who encourages patient participation and preventive dentistry.

Even the best-looking office, however, can harbor health hazards for you if you are an unwary dental consumer. Slipshod office procedures and inadequate or defective equipment can spell disaster in an emergency or expose you to unnecessary risks of infection or excessive x-rays. So take time during your get-acquainted visit to evaluate the office’s safety, based on the following information.

Budget Alternatives
If the cost of dental care in a private office has kept you from seeking care, you may want to investigate the availability of any of several lower-cost alternatives.
Government Clinics
The federal government funds more than 550 clinics called community health centers in designated medically underserved areas. These clinics are required to provide preventive dental care, especially for children and adolescents, who comprise about one-third of patients seen in these clinics. About half of the facilities also provide primary care services such as fillings.
Active duty military personnel receive comprehensive dental care through the Department of Defense medical system. While active duty personnel have first priority, their families and retirees can also receive dental care through this system, including emergencies, routine preventive care and restorative procedures such as fillings and crowns.
The Veterans Administration provides dental services for both service-connected and nonservice-connected visits to those patients who qualify for VA benefits by virtue of service-related disability.

Despite significant funding cuts, about 140 dental clinics, sponsored by city or county governments, are available. You may also find that major hospitals that operate outpatient medical clinics for Medicaid recipients and other people with low incomes may also provide at least some dental services. In all cases, services and administrative policies vary significantly from program to program, as do fees. Many use a sliding fee scale or copayment system, with fees based on your ability to pay. Be prepared to substantiate your financial circumstances and other qualifications, such as union membership or former military service.

In 1986, researchers at Ohio State University analyzed local dental clinics in 31 states. Almost all of the 144 clinics provided preventive care such as cleanings, basic restorative care such as fillings, and emergency care. Almost none provided orthodontic care. This survey also found that over a quarter of the clinics had no program in place to evaluate the quality of care, less than half required dentists to wear gloves with all patients, and only a quarter required staff to be vaccinated against hepatitis B. If you seek care in any low-cost facility, do not accept substandard care. Ask the questions we’ve outlined; insist that basic infection control procedures be carried out.
Dental School Clinics
Another low-cost alternative is available to those who live near a dental school. In order to provide patient-care experience for their students, these schools operate clinics in which third- and fourth-year students carry out procedures under the direct supervision of faculty. As a general rule, these clinics do not emphasize prevention; the students are there primarily to learn to restore teeth, perform root canals and practice applying other ”hands-on” techniques.

The Many Sides of Safety

Emergency Preparedness.
Two surveys of more than 4,300 dentists, reported in 1992, found that during a 10-year period, each dentist experienced an average of seven medical emergencies resulting from dental care. The most common emergency, faintingwhich can be caused by anxiety, among other factorsaccounted for half the emergencies reported. Depending upon the individual circumstances, fainting sometimes carries the risks associated with a drop in blood pressure, breathing difficulties and central nervous system disruption. A person with diabetes who doesn’t eat before a visit may experience dangerous blood-sugar levels. An allergy to anesthesia may cause serious breathing problems.

While these conditions are serious, they are reversible if prompt and appropriate medical care is provided. Unfortunately, a general dentist’s education “provides little preparation for management of life-and-death situations,” comment Robert M. Peskin, D.D.S., and Louis I. Siegelman, D.D.S., in a 1995 article in Dental Clinics of North America. Yet responsibility for emergency management rests solely with the dentist, because government oversight of the dental office is minimal or nonexistent. Inspections may come only as a result of consumer complaints or focus on other aspects of safety such as infection control or x-ray equipment.
Your get-acquainted visit gives you a chance to ask some basic questions about your dentist’s ability to handle emergencies:
۱٫ What training in medical emergency management have you had?
Six of 10 dental schools do not have a separate course in emergency training, but instead incorporate the topic into other courses. As a result, general dentists may have 10 or fewer hours of emergency training during dental school. And they probably had no experience in applying that training because only 22 percent of dental schools conduct emergency drills. Students are required to be certified in cardiopulmonary resuscitation (CPR) at the start of their schooling, but one in eight dental schools has no program to maintain certification throughout the four-year program. Furthermore, after graduation dentists may allow their certification to lapse if they live in a state that doesn’t require CPR certification for licensing. Dentists who complete postgraduate work to specialize in pediatric dentistry, oral surgery or dental anesthesiology have additional courses in medical emergency management during their residency, and must be certified in advanced cardiac life support (ACLS). Training in ACLS includes the proper use of cardiac monitors, oxygen administration and intravenous medications to stimulate the heart in emergencies.
Dental hygienists must also be certified in CPR during their training. They receive between one and 64 hours of medical emergency training, depending on the school, with two-thirds of schools incorporating the subject into other courses. In 45 percent of hygienist schools, students test their preparedness with emergency drills.
Most states test knowledge of emergency procedures on the written portion of their licensing examination for dentists and hygienists.

۲٫ What plans do you have in place for dealing with emergencies?
Peskin and Siegelman provide a checklist for dentists to prepare themselves and their staffs for emergencies. It can also serve as a guideline as you visit prospective offices and talk with dentists and their staffs.
Find out the following:
ò Are all staff members currently certified in CPR?
ò Do all staff members have assigned tasks in case of emergency?
ò Have contingency plans been made to cover all emergency tasks in the event a staff member is absent?

ò Are periodic unannounced mock emergency drills carried out?
ò Are appropriate emergency telephone numbers posted prominently next to all telephones?
ò Is the oxygen tank checked regularly? And is other emergency equipment on hand, in good working order, and located where the emergency plan indicates?
ò Are all emergency medications checked weekly and replaced when used or expired?
ò Has a specific staff member been assigned to complete this checklist regularly?
Adapted from Robert M. Peskin and Louis I. Siegelman, “Emergency Cardiac Care: Moral, Legal and Ethical Considerations,” Dental Clinics of North America 39, no. 3 (1995): pp. 677û۶۸۸٫
Infection Control.
The need for patients to be vigilant for potential gaps in an office’s infection control procedures is unfortunately very real. Any virus or bacteria carried by blood, such as the hepatitis virus, or by saliva, such as the tuberculosis virus, can potentially be transmitted in a dental office. At least nine dental workers infected 147 patients with hepatitis B virus between 1970 and 1987, and one dentist infected six patients with the human immunodeficiency virus in the early 1990s. Because the source of an infection can be very difficult to trace in isolated cases, the actual number of patients infected by the various viruses and bacteria commonly found in modern dental offices is likely to be much greater.
Transmission of infectious diseases to dental patients can happen via three routes. First, the dentist (or hygienist) who is infected passes the illness on to the patient through blood from a cut on the dentist’s ungloved hand. Second, equipment or instruments contaminated by one patient and not properly sterilized can pass illness on to another patient. Third, airborne contaminants in saliva droplets from the infected dentist’s unmasked face can transmit disease during therapy.
In 1991, the Occupational Safety and Health Administration (OSHA) issued standards to protect employees of dental offices from infection. Many of the Page 60
ò Are periodic unannounced mock emergency drills carried out?
ò Are appropriate emergency telephone numbers posted prominently next to all telephones?
ò Is the oxygen tank checked regularly? And is other emergency equipment on hand, in good working order, and located where the emergency plan indicates?
ò Are all emergency medications checked weekly and replaced when used or expired?
ò Has a specific staff member been assigned to complete this checklist regularly?
Adapted from Robert M. Peskin and Louis I. Siegelman, “Emergency Cardiac Care: Moral, Legal and Ethical Considerations,” Dental Clinics of North America 39, no. 3 (1995): pp. 677û۶۸۸٫
Infection Control.
The need for patients to be vigilant for potential gaps in an office’s infection control procedures is unfortunately very real. Any virus or bacteria carried by blood, such as the hepatitis virus, or by saliva, such as the tuberculosis virus, can potentially be transmitted in a dental office. At least nine dental workers infected 147 patients with hepatitis B virus between 1970 and 1987, and one dentist infected six patients with the human immunodeficiency virus in the early 1990s. Because the source of an infection can be very difficult to trace in isolated cases, the actual number of patients infected by the various viruses and bacteria commonly found in modern dental offices is likely to be much greater.
Transmission of infectious diseases to dental patients can happen via three routes. First, the dentist (or hygienist) who is infected passes the illness on to the patient through blood from a cut on the dentist’s ungloved hand. Second, equipment or instruments contaminated by one patient and not properly sterilized can pass illness on to another patient. Third, airborne contaminants in saliva droplets from the infected dentist’s unmasked face can transmit disease during therapy.
In 1991, the Occupational Safety and Health Administration (OSHA) issued standards to protect employees of dental offices from infection. Many of the standards, enacted into federal law, simultaneously protect patients. For example, workers are required to wear gloves and masks.

The law also allows OSHA to inspect dental offices and issue fines for offenders. However, inspections are not mandatory for all offices, but instead come as the result of employee complaints. Again, the emphasis of these inspections is on employee protection, not patient safety.
Guidelines for effective infection control have also been issued by the Centers for Disease Control and Prevention and the American Dental Association. However, these do not carry the force of law or impose penalties on dentists who do not follow the guidelines.
At the state level, the examination that dentists take for initial licensing, described in chapter 1, includes questions about proper infection control procedures. This, of course, tests knowledge, not actual practice. To find out if your state goes further and inspects dental offices for infection control measures, call your state board of dental examiners. In most cases, you’ll find that no one regularly monitors a dentist’s compliance with infection control standardsno one except you, the alert consumer.
Consistency is essential in applying infection control procedures. This concept, initiated by the Centers for Disease Control and Prevention, is known as universal precautions. It means that procedures are carried out as if all patients’ blood and saliva carry infectious agents. In other words, the same precautions are used for all patients. The dentist who thinks that she needs to practice infection control only with patients she believes are high risk is endangering herself, her staff and her other patients. Yet studies repeatedly show that some dentists and their staffs apply the guidelines only when it is convenient or they believe a risk exists.
During a brief get-acquainted visit, of course, you cannot observe consistent behavior over time. You also cannot observe how well some of the procedures are actually carried out because they take place before the office opens. Nevertheless, there are questions you can ask and some activities you can observe. Once you have selected a dentist, you will have to remain vigilant before and during dental procedures. See chapter 3 for additional information about specific infection control procedures, including those that involve dental equipment.
Here, let’s look at what infection control procedures are supposed to accomplish. As we’ve noted, infection can be transmitted via direct contact with blood or other body fluids, indirect contact with contaminated instruments or equipment or contact with airborne contaminants such as droplets from a cough. Three things are needed in order for infection to occur: (a) a susceptible host (patient or dental worker), (b) virus or bacteria at levels high enough to cause disease and (c) a way for the virus to enter the body (mouth or nose). Infection control procedures are designed to eliminate one or more of these elements, thus preventing a complete cycle and infection. To learn more about how your dentist protects you, ask the following:
۱٫ Do you have a written infection control plan? Who is responsible for carrying it out? What training does she have?
Every dental office should have a written infection control plan in place that outlines the procedures to be followed, when they are to be used and who is responsible for carrying them out. Ask to see the plan in any office you visit.
Having a written plan doesn’t ensure that it is followed, of course. A study of disinfection of clean water units designed to provide water, independent of the local water supply, to the dental handpiece and water syringe found that only one dentist in five was following the manufacturer’s written instructions for disinfection. Your own questions and observations can help verify in at least some instances that infection control procedures are being carried out as written.
You can’t see them, of course, but bacteria and viruses cling to instruments and equipment. Any effective infection control process must include these items. The Centers for Disease Control and Prevention recommend the following:
ò All instruments that penetrate gums or bone or come into direct contact with mouth tissues should be cleaned, preferably by an ultrasonic device, and then sterilized with heat between each use.
ò Instruments that are not being used immediately after sterilization should be packaged for storage.
ò Items such as the handle of the examining light or x-ray unit heads should be covered with plastic, aluminum foil or other barriers that are changed after use with each patient.

After each patient and at the end of the day, countertops and other surfaces in patient care areas should be wiped with disposable towels and disinfected with a solution of bleach and water or a germicide labeled as a “hospital disinfectant” and “tuberculocidal,” in the latter case meaning that it is effective against the tuberculosis bacterium.
ò After each patient, water lines to the high-speed handpiece and water syringe should be run 20 to 30 seconds to flush water and air into a sink or container. They should also be flushed for two to three minutes at the beginning of each day.
ò Whenever possible, disposable instruments should be usedfor example, the tip of saliva ejectors or cleaning brushesand replaced after each patient.
An assistant or hygienist usually carries out most or all of these tasks, so you may want to ask her, in addition to the dentist, about how they are handled in the office. Some dentists recognize that infection protection is important to patients and have prepared brochures or letters describing their efforts. Ask if one is available.
Both the staff and the equipment need to be scrutinized. For example, anyone working in your mouth should wash her hands before starting; she should wear latex or vinyl gloves, eyeglasses and a surgical mask (or a plastic face shield that covers eyes, nose and mouth). She should also wear protective clothing such as a laboratory coat, uniform or disposable gown, which is changed daily or when it becomes visibly soiled. A 1992 study of Chicago dentists found that while 90 percent wore gloves and 79 percent wore protective clothing, only about 62 percent wore either a face mask or eye protection. These items are fundamental to infection control today; do not even consider a dentist who does not follow these basic procedures.
۲٫ Do you take a written medical and dental history for new patients? How often do you update it?
A complete history should be taken when you first become a patient and updated at each office visit. Between 75 and 90 percent of the Chicago dentists surveyed took an initial history. However, other studies have found that as few as one in three dentists take an initial history and make regular updates.

۳٫ Have you and your staff been vaccinated against hepatitis B? Do you have annual tuberculosis tests?
The dentist and her staff should be vaccinated against hepatitis B virus. Hepatitis B is a disease of the liver that can be transmitted by the blood of an infected person. It can become chronic and lead to cirrhosis and other liver damage. Hepatitis B infection is the most commonly acquired blood-borne infection found in dental workers. Dentists have almost twice the rate of infection as the general population, even with the availability of a vaccine, introduced in 1982. According to an American Dental Association survey, 85 percent of dentists reported receiving the vaccine by 1992. The survey found that the longer a dentist had been in practice, the less likely she was to have had the vaccine and the more likely she was to have been infected.
OSHA now requires all dental workers who come into direct contact with patients to be vaccinated against hepatitis B. The vaccine protects them from infection by the hepatitis B virus and thereby from passing it on to you and other patients.
If you live in a major metropolitan area, each dental employee should undergo annual tests for tuberculosis. This is particularly true in New York, California and Texas, where the rate of reported tuberculosis cases in the general population rose 84 percent, 54 percent and 33 percent, respectively, between 1985 and 1992.
X-Ray Safety.
In modern dentistry, an x-ray examination is the only way that dental diseases below the gum line or inside the tooth can be diagnosed. Without x-rays, specialized dental work such as root canal therapy and orthodontics cannot be done.
But x-rays, even the low-level x-rays of dentistry, still carry risks. In 1995, Robert P. Langlais, D.D.S., M.S., and Olaf E. Langland, D.D.S., M.S., from the University of Texas Health Science Center at San Antonio, published an analysis of the current risks from dental radiation. Reviewing numerous studies, Langlais and Langland made the following assessments:
ò For every million full-mouth x-ray examinations (16 to 24 views of all teeth taken at one time) performed, less than one extra case each of leukemia, lung cancer and thyroid cancer can be expected.

Overall, for every million full-mouth x-ray examinations performed, 2.5 extra cases of cancer of all types can be expected.
ò The risk of death from dental x-rays is about one in a million, comparable with smoking one cigarette or riding your bicycle for 10 miles.
ò While a theoretical risk of cataract formation exists, in practice the level of radiation exposure to the eye is so low that, according to Langlais and Langland, “the risk of producing damage is remote.”
Two University of California at Los Angeles professors, Susan Preston-Martin, Ph.D., and Stuart C. White, D.D.S., Ph.D., have closely examined the relationship of brain and salivary gland tumors to dental radiation. They conclude that of the eight cases of parotid gland (the largest salivary gland) cancer per million people in Los Angeles, one is caused by dental radiography. They also found that children diagnosed with brain tumors at the age of 15 to 24 years were two-and-one-half times as likely to have had five or more sets of full-mouth x-ray examinations as were young children with similar tumors.
Over the years, efforts have been made to reduce both the frequency and the radiation level of x-rays. In 1988, for example, the U.S. Food and Drug Administration issued guidelines to help dentists reduce the number of x-ray examinations performed. Those guidelines were approved by the American Dental Association and other dental organizations. If you are an adult with normal teeth and gums and no more than an occasional cavity, you can reduce your exposure by 40 percent by visiting a dentist who follows these guidelines:
ò At your initial visit, bitewing views of your back teeth should be taken to provide a baseline for future comparisons as well as to identify any problems that need immediate attention. These x-rays show the crown and part of the root of two or three pairs of opposing teeth, especially the large molars at the side and back of the mouth. Bitewings may also be needed for specific circumstances, such as assisting the dentist in carrying out a root canal procedure. If you are changing dentists and have a full set in your previous medical record, ask to have it transferred to the new dentist. Bitewings should be taken every 18 to 36 months.
ò Periapical x-rays show both the visible crown of the tooth and its entire root. These views are no longer recommended routinely for a healthy person’s initial office visit. Periapical views should be taken only after a comprehensive examination identifies the presence of certain conditions such as unusual tooth color, pain, unexplained tooth sensitivity to temperature or pressure, or a history of periodontal disease.
Careful questioning during your get-acquainted visit will help you further reduce your risk from dental x-rays. Among the questions to ask are:
۱٫ Who takes patient x-rays? What training and/or experience does she have? Is she certified/licensed to do so?
Equally important to the frequency of the x-ray examination is the quality of the x-ray. Modern equipment and high-speed film have made the procedure relatively simple and fast, but it is still important that the operator know what must be done to ensure accuracy, readability and patient safety. A 1996 study reported in the Journal of the American Dental Association, for example, found as many as 20 percent of dental x-rays were unacceptable in that they did not provide an image that was clear, undistorted or otherwise accurate enough to be useful to the dentist. Other reports have found even higher levels.
A dentist must determine the need for x-rays, but the dentist, hygienist and, in some states, assistant can take the actual x-ray. Your state dental practice act specifies who can take them and whether licensing or registration is necessary. In 1981, the federal Consumer-Patient Radiation Health and Safety Act was passed to update requirements for those who take x-rays, but many states still do not have legislation in place to carry out the federal mandate. Connecticut, for example, put into effect “An Act Concerning X-Ray Safety” in October 1993, requiring that all dental assistants who take x-rays must pass the Dental Assisting National Board’s radiography examination by January 1, 1995. However, as many as 14 states still have no requirements for assistants who take radiographs.
Training for dentists and dental hygienists includes courses in radiation safety and procedures, and licensing examinations have a section on the topic. The certification program for dental assistants, described in chapter 1, includes course work and an examination on radiation safety and procedures as well.

۲٫ What type of protective equipment do you use for patients?
During your visit, ask to see the x-ray equipment and protective devices used for patients. The equipment should have a long (about eight inches) lead-lined rectangular tube that is aligned next to your cheek, rather than a short, pointed plastic cone. The rectangular tube provides a narrow beam and exposes the least area to radiation, reducing skin exposure as much as 50 percent compared with the cone, according to several reports, including one in 1995 by Jack N. Hadley, D.D.S., assistant professor of radiology at the University of the Pacific School of Dentistry in San Francisco. Patients should wear a lead apron and collar for all x-rays to protect the thyroid gland, which is particularly susceptible to radiation, and other organs from unwarranted exposure.
۳٫ How do you monitor the radiation dose given by the machine?
Poor maintenance and other factors can cause machines to emit more radiation than they are supposed to or is necessary. The dentist can easily monitor the dose by using an inexpensive device called a dosimeter or a radiation-monitoring-by-mail service, in which lapel badges worn by dental staff are sent on a regular basis to an off-site laboratory for calculation of exposure.
۴٫ Do you use Ektaspeed x-ray film (also called E film)?
This is a rapid-speed, high-resolution, short-exposure film that reduces the length of time a patient is exposed to radiation compared with the previous D film. Note, however, that a survey of nearly 2,000 California dentists in 1995 found that only 21 percent were using E speed film.
While these issues of safety are important to evaluate during your get-acquainted visit and to weigh in your final choice of a dentist, they should remain issues of concern throughout your dental care. Remain alert and be willing to ask these questions about emergency preparedness, infection control and x-ray procedures anytime you suspect standards may have fallenfor example, when new staff members join the practice or the dentist seems particularly busy.
Your concern for safety carries over to other dental settings as well. Ambulatory care centers, for medical, surgical and dental care, have grown in popularity in recent decades as a result of improvements in anesthesiology, demand by managed care plans, among others, for shorter hospital stays and consumer preference. Nevertheless, if your dentist recommends that you undergo dental care at an ambulatory center, you need to evaluate it as carefully as you did the dental office and staff.
Ambulatory Care Centers
Ambulatory care centers provide care that does not require an overnight stay in a hospital. This can include medical procedures such as kidney dialysis, surgery such as cyst removal and dental procedures ranging from several restorations to implant surgery (surgery to place a metal base into the jaw to which artificial teeth can be permanently attached).
More than 28 million ambulatory surgery procedures of all kinds were performed in 1996, of which about 222,000 involved teeth, gums and tooth sockets.
Dental procedures may be performed at a general ambulatory center or one specializing in dentistry. Large hospitals (with 400 beds or more) and those affiliated with universities that train dentists are most likely to have specialized dental centers. About 1,000 U.S. hospitals have such centers. Nine of 10 hospital-owned dental centers are located within the hospital itself, with the others situated adjacent to the hospital or in a few instances at off-site, freestanding facilities.
Dental centers can also be owned and operated by dentists, individually or as part of a group, and less commonly by government agencies or nonprofit organizations.
When choosing one setting over another, quality, not convenience, must be the deciding factor.
Before you go to an outpatient center for surgical care, find out as much as possible about its facilities and staff. Visit the facility and speak with the director or other supervisory staff. In particular:
ò Find out the center’s licensing and certification status. Not all states license these facilities, but if your state does, then avoid an unlicensed center. Call your state department of health to find out its responsibility and the status of the center you have chosen.

When the Dentist Says Outpatient Surgery
When your dentist recommends surgery, she will indicate whether it can be done on an outpatient basis and where she would like to perform it. Among the questions you want to ask her are the following:
۱٫ Is a nonsurgical alternative available? Why have you recommended surgery?
۲٫ What happens if I don’t have the surgery? Is there any advantage or disadvantage to waiting?
۳٫ Will you perform the surgery? If so, how often have you done so? What complications do your patients commonly experience? Have your patients experienced any serious or permanent side effects?
۴٫ Why do you want to do this on an outpatient basis? Does this surgery carry any additional risks when performed on an outpatient basis?
۵٫ What percentage of patients undergoing this surgery as outpatients have been admitted to the hospital with complications necessitating an overnight stay (or longer)? What were the complications?

۶٫ Why do you want to perform the surgery at this particular center? Could you perform it at another ambulatory center or in your office?

surers certify facilities in the areas of safety, cleanliness and preparedness for emergencies. The facility’s business manager or your insurance company can tell you if it has such certification. Finally, centers can voluntarily apply for accreditation by the Joint Commission on Accreditation of Healthcare Organizations or the Accreditation Association for Ambulatory Health Care. The review processwhich, by the way, the facility pays for the privilege of undergoingevaluates quality-assurance measures, staffing and a wide range of other criteria. Unfortunately, few non-hospital-based centers have undergone the process. Most centers prominently display their certification letter, but you can also check the center your dentist has recommended by contacting either organization:

Accreditation Association for Ambulatory Health Care
۹۹۳۳ Lawler Ave., Suite 512
Skokie, IL 60077-3708

Joint Commission on Accreditation of Healthcare Organizations
One Renaissance Blvd.
Oakbrook Terrace, IL 60181
What Is JCAHO?
The Joint Commission on Accreditation of Healthcare Organizations was founded in 1951 (as the Joint Commission on Accreditation of Hospitals) by the American College of Surgeons, the American Hospital Association, the American Medical Association, the American College of Physicians and the Canadian Medical Association (which withdrew in 1959). The American Dental Association was added in 1979.
The commission was incorporated as a private not-for-profit organization with a 22-member board of commissioners and later expanded to 24 members with the following representation:

American Hospital Association and American Medical Association, seven seats each; American College of Physicians and American College of Surgeons, three seats each; American Dental Association, one seat; and three public members. Public members are not representatives of any consumer organizations and, unlike the other representatives on the board, who are appointed by their sponsoring organization, the public members are appointed by the board itself.
JCAHO’s stated purpose is to improve the quality of health care to the public.
Some 5,300 hospitals and 3,600 other health care programs are JCAHO inspected and accredited. JCAHO has programs that accredit general and psychiatric hospitals, home-care organizations, nursing homes and other long-term-care facilities. The group also has programs to accredit psychiatric services such as substance abuse programs, community mental health centers, programs for the mentally retarded, and adult and adolescent psychiatric programs. It also accredits outpatient surgery centers, urgent-care clinics, dental and other group practices, preferred provider organizations and community institutions.
JCAHO funding comes from fees charged to institutions and other programs. The organization’s yearly operating budget is around $50 million.
Fewer than 1 percent of hospitals inspected by JCAHO fail to meet accreditation standards.
Over the last decade, a great deal of controversy has swirled around the organization. The People’s Medical Society and other consumer groups have suggested that JCAHO is a prime example of the foxes guarding the chicken cooptypical of the health care system in the United States. A 1988 expos in the Wall Street Journal raised serious questions about the credibility of the organization’s inspection process. In 1990, then-Medicare-director Gail Wilensky, in testimony before the House Ways and Means Committee, noted concerns with JCAHO’s hospital-accreditation program, which is used as the primary basis for deciding whether a hospital will be included in the Medicare program.
Despite these varied concerns, JCAHO remains the only technically independent body reviewing all aspects of a facility’s operation.ò Investigate the center’s staff and their credentials. Call your state’s licensing boards and make sure all the doctors, dentists and nurses who work there are licensed. During your get-acquainted visit to the center, ask about board certification and the specialties of the dentists and physicians on staff. As we have said before, certification does not guarantee quality care, but it is an important indicator.
Dentists who care for patients in hospital-based centers must have admitting privilegesi.e., the hospital has reviewed the dentists’ education, licensing and other credentials and authorized the dentists to admit and care for their patients in the hospital and its facilities. About 40,000 dentists, specialists as well as generalists, have these privileges. If your dentist doesn’t, it doesn’t mean that she is not qualified. Instead, she may not treat enough patients needing hospital-based care and so may not apply for privileges. In such a case, your dentist will refer you to a dentist who has privileges.
Dentists in hospital-based centers may be on the staff full-time; they may also work there part-time and maintain a private office elsewhere; some may be volunteers as part of a rotating community service. All will have undergone the process of evaluation for admitting privileges.
Privately owned centers are staffed by a mix of dentist-owner(s) and/or paid staff dentists, many of whom are newly graduated from dental school.
You will also find dental assistants and hygienists employed in all types of dental centers.
Nurses provide a significant portion of the care in ambulatory settings, especially in surgery centers. Before any scheduled surgery, a nurse should call you to answer questions and give you final instructions to prepare for your visit. A nurse will closely monitor you in the recovery room and, using preestablished criteria, may advise your dentist on your readiness for discharge. Furthermore, a nurse should answer your questions and give you information on postoperative care, and certainly should call you the day after the surgery to check on your status.
The nursing staff should be comprised of registered nurses or nurse practitioners, permanently assigned to the outpatient center. Look for a low nurse-to-patient ratioperhaps one nurse to every three or four surgical patients.

In an outpatient clinic at a teaching hospital, resident physicians and dentistsessentially, students-in-trainingrotate through the clinic, changing every few months. Continuity of care is often assured by the nursing staff. Ask about the nursing turnover rate. A low rate is one indicator of a satisfied staff committed to outpatient care.
For successful same-day surgery without complications or the need for a hospital stay, anesthesia must be carefully and expertly given. Make sure that a board-certified anesthesiologist will administer the anesthesia and be present during the surgery. Ask to meet him before your surgery. (See chapter 3 for more on anesthesia risks.)
ò Take a look around at the equipment and atmosphere. Here you must look beyond the decorating touches to the overall cleanliness of the waiting area, examining rooms and recovery area. Are equipment, files, medications and other visible items maintained in an orderly fashion? Is the recovery room adequately equipped for the number of patients being served, and is privacy maintained? Overall, is the atmosphere professional, yet friendly? If it is a hospital-based surgery center, are the ambulatory patients treated in a separate area, with its own recovery room, staff and reception area? If not, you may be left to recover with other, more seriously ill patients and may not receive the attention you deserve.
ò Evaluate the facility’s emergency preparedness. If the center is not hospital-based, ask about procedures for emergency transfer to a hospital if you should become seriously ill during or immediately after surgery. Ask how the center works with local hospitals and ambulance services. Should the need arise, can the center arrange rapid transportation to a hospital? Which hospital is used? Does the center’s staff call an ambulance, and if so, which one? Do they have an emergency communication system with the hospital?
ò Find out the center’s fees and billing policies. Do not assume that the fees for all services at one ambulatory center are the same as fees at others or that this is the lowest-priced alternative. Ask. Find out how payment is to be made and whether a sliding fee scale is available, if you are on a limited income. Must you pay at the time of treatment? Credit card or cash only, or can a payment schedule be arranged? What health coverage does the center accept? If you are covered by an HMO or other managed care plan, is the center part of the plan’s provider network? (If not, you may have to pay most or all of the fees. Check your member’s handbook or ask the plan administrator for details.)
ò Find out the number of surgeries the center performs a year. More and more studies are corroborating what many people have long suspected regarding quality of surgical care: Practice makes perfect. Also ask the dentist how many times a year she performs the procedure you are about to undergo.
Ambulatory care can be convenient, safe and cost-effective, but, as with other fast-growing fields, inconsistencies in quality and service do exist. Take the time before you use the facility’s services to evaluate the care you can expect.
When Hospital Care is Called For
These days, in just about every community, competition among hospitals is intense. Hospital-sponsored newsletters and advertisements tout each facility as providing comprehensive care in a high-quality, hightech setting. But can they all be the best? How can you sift through the competing claims? What really matters when it comes to hospital care? While, admittedly, the vast majority of dental procedures and dental consumers do not require hospital-based care, nevertheless it is important to be prepared. Let’s consider some of the factors.
Your Choice of Hospital
There are about 5,300 hospitals in the United States, according to the American Hospital Association. At first glance, it may seem that ”a hospital is a hospital is a hospital,” but the differences among the various typescommunity, medical center, teaching and specialty hospitalscan affect your care. Let’s first look briefly at each type, then consider how to go about evaluating the care you will receivebefore you need it.
Community Hospitals Versus Medical Centers.
Community hospitals, as the name implies, dot the landscape of residential communities. They market themselves as one of your neighbors. The distinction between a community hospital and medical center is not clearly defined,however. For marketing purposes, a hospital may choose one or the other designation, so don’t be fooled by the name. Both facilities may offer many of the same services, especially those related to dental surgery.
A community hospital may range from as few as 50 to as many as several hundred beds. A good-size community hospital has around 250 beds, and it offers general surgical, diagnostic, medical and often obstetrical services. It usually has every kind of high-tech medical gizmo needed to provide basic and competent care. Its operating room has the equipment necessary to perform dental surgery, although the room may be used for other surgical procedures as well. Larger community hospitals are likely to have CAT scanning, x-ray, and other diagnostic and therapeutic equipment for modern care.
If you are admitted to a small community hospital for a nondental reason and need dental care during your stay, dental services are likely to be provided on a consulting basisthat is, your physician calls in a dentist from the community who has privileges at the hospital. In larger community hospitals, one or more dentists may be employed full-time as members of the department of surgery or emergency medicine or, less commonly, of a separate department of dental medicine. Most specialists are available as consultants. If you are being admitted by your own dentist for a dental procedure, then she will provide your care whether it is a small or large community hospital.
A medical center is often (but not always) large, is affiliated with a university and offers the highest level of care, known as tertiary care. (Tertiary care frequently requires highly sophisticated technology and highly specialized practitioners in the performance of such diagnostic and therapeutic services as high-tech scanning, organ transplants, burn care, multiple-trauma care and open-heart surgery.) Its facilities may include specialized intensive-care units, a range of surgical services and an emergency department equipped to handle serious trauma victims. Medical centers argue that because of the sheer number of patients they treat, they are experienced in the care of many rare or complicated disorders. They attract well-trained specialists to their staffs and offer the latest in medical technology.
This is often true of their dental service as well. A full range of specialists are on staff full- or part-time, either in a separate department of dental medicine or as part of the department of surgery or emergency medicine. One or more operating suites are set up for dental procedures with a dental chair designed to enable the patient to be moved under sedation from a gurney to the chair. If the medical center is affiliated with a university dental teaching program, patients have 24-hour emergency access to resident dentists.
However, the characteristics of large medical centers are not always beneficial. Unless the need for such a facility is completely demonstrable, many of the attractions of such a facility may be the equivalent of a medical backfire. For example, the large size may contribute to your stress and may put policy roadblocks in the way of your active concern for your care. The greater numbers of staff, patients and visitors expose you to a greater risk of hospital-acquired infections. The presence of costly pieces of equipment makes it more likely you will undergo tests and procedures to put these devices and their technicians to work.
In the final analysis, keep in mind that a hospital’s size is not always a reliable clue to the kind of treatment you can expect there. You might have a warm and caring experience at a 700-bed behemoth of a medical center, and you might be treated like yesterday’s laundry at a 100-bed community hospital.
Teaching Versus Nonteaching Hospitals.
The arguments for going to a teaching hospital are just about the same as ones for going to a medical center: expertise, the newest technology, the latest knowledge. In fact, many of the best and best-known teaching hospitals are university medical centers. About 125 of the approximately 1,500 teaching hospitals are academic medical centers, according to a report in the American Medical News.
There is no shortage of doctors in a teaching hospital. During a stay of even a few days, you may be seen by any or all of the following:
ò One or more staff doctors and dentists, who are full-time employees of the hospital. They administer the hospital’s teaching program, teach medical and dental students and help care for patients. Some world-renowned staff specialists may have little actual contact with most patients, except perhaps those with rare disorders. These doctors lend their prestige to the hospital and add to the overall cost of care.

ò Your own community-based dentist/oral surgeon
ò Your own physician, especially if you have a medical condition such as heart disease that could affect your dental health. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires medical supervision of dental patients in such cases.
ò A resident or many residents who have their M.D., D.D.S. or D.M.D. degrees (they may or may not be licensed) and have completed an internship and are continuing postgraduate training in a specialty
ò A medical or dental student or, more likely, many medical and dental students, who aren’t really doctors/dentists at all but instead are in their third or fourth year of medical/dental school
Medical and dental schools place their students in university hospitals and medical centers and in affiliated community hospitals. (In fact, these hospitals exist as much for the education of medical and dental students as they do for the care of patients.) A teaching hospital has 24-hour physician coverage provided by these residents and interns, including emergency dental care. The hospital must be accredited by the Joint Commission on Accreditation of Healthcare Organizations and by the appropriate medical and dental specialty boards.
Cost may be another factor in deciding between a teaching and a nonteaching hospital. Teaching hospitals have greater expenses than nonteaching hospitalsthe salaries paid to postgraduates-in-training, the money it takes to attract top-flight experts, the enormous sums paid for new technological marvelsand fewer patients at teaching hospitals pay their bills. So it’s no wonder the average cost of care in a teaching hospital can be as much as twice that of a nonteaching hospital.
Evaluating a Hospital
Evaluating a hospital, like finding a qualified dentist, takes some time and research, but your efforts can pay off in better care and less anxiety and worry for you.

At the very least, the hospital should be accredited by JCAHO. About 75 percent of hospitals have undergone these voluntary inspections, which have traditionally concerned themselves largely with procedural rather than quality issues.

What the wary consumer must keep in mind is that to seek accreditation is a voluntary act for a hospital. As with ambulatory care centers, hospitals pay for a survey, and this on-site visit is scheduled in advance, so the hospital has time to prepare and, if necessary, clean up its act. In the accrediting process, teams of investigators arrive at a hospital that has either applied for the first time or is up for renewal, which is every three years. An extensive list of itemsfrom nursing care to hospital administration, food service to medical recordsis studied and inspected to see if the standards are sufficiently high. The hospital’s section or department of dental medicine must comply with the same set of standards as other departments.
The stated aim of accreditation is to set and promote high standards of quality and to reward those institutions that achieve those standards. In some cases, it may take several inspections before a hospital satisfactorily meets them. Hospitals that fail to meet standards are given an opportunity to correct the problems before another inspection.
But the seal of approval doesn’t tell the whole storyaccreditation procedures might uncover minor glitches in the dental operating room, but they don’t always pick up major deficiencies in the humaneness of the staff or in the facility. These things you have to monitor and question for yourself.
A telephone call to the hospital’s chief administrator can usually get you its accreditation status. Most hospitals post their current accreditation certificate in their lobby. Or you can contact JCAHO directly (see page 70).
One thing to keep in mind about accreditation: JCAHO approves nearly all hospitals inspected, so once again the burden remains largely on you to perform your own inspection, get your own facts and make your own assessment of the hospitals in your community.
Nursing Staff.
Nurses are the most important staff members in a hospital and certainly the professionals you face most often during a hospital stay.
People hospitalized for dental therapy are cared for along with other medical and surgical inpatients.

What the wary consumer must keep in mind is that to seek accreditation is a voluntary act for a hospital. As with ambulatory care centers, hospitals pay for a survey, and this on-site visit is scheduled in advance, so the hospital has time to prepare and, if necessary, clean up its act. In the accrediting process, teams of investigators arrive at a hospital that has either applied for the first time or is up for renewal, which is every three years. An extensive list of itemsfrom nursing care to hospital administration, food service to medical recordsis studied and inspected to see if the standards are sufficiently high. The hospital’s section or department of dental medicine must comply with the same set of standards as other departments.
The stated aim of accreditation is to set and promote high standards of quality and to reward those institutions that achieve those standards. In some cases, it may take several inspections before a hospital satisfactorily meets them. Hospitals that fail to meet standards are given an opportunity to correct the problems before another inspection.
But the seal of approval doesn’t tell the whole storyaccreditation procedures might uncover minor glitches in the dental operating room, but they don’t always pick up major deficiencies in the humaneness of the staff or in the facility. These things you have to monitor and question for yourself.
A telephone call to the hospital’s chief administrator can usually get you its accreditation status. Most hospitals post their current accreditation certificate in their lobby. Or you can contact JCAHO directly (see page 70).
One thing to keep in mind about accreditation: JCAHO approves nearly all hospitals inspected, so once again the burden remains largely on you to perform your own inspection, get your own facts and make your own assessment of the hospitals in your community.
Nursing Staff.
Nurses are the most important staff members in a hospital and certainly the professionals you face most often during a hospital stay.
People hospitalized for dental therapy are cared for along with other medical and surgical inpatients. The nurses who care for them are, in general, responsible for preventing infection, teaching the patient post your temperature and other vital signs, giving injections and bathing you. In some states, they are also allowed to give medications and set up intravenous tubes, which allow you to be fed or receive drugs through your veins.
Nurses’ aides (or nursing assistants) have the least training, skills and autonomy. They may complete a vocational school program or even be trained by their hospital employers. Their duties are supervised by doctors, R.N.’s and L.P.N.’s, and can range from delivering messages to bathing newborns. They may escort you to the x-ray department and take and record your vital signs.

operative care, assuring postoperative nutrition and helping the patient manage pain.
Support Staff.
In a 1990 survey by researchers from the Northwestern University Dental School of 1,755 U.S. hospitals, about one-third indicated that they had one or more dental hygienists on staff. Hospitals with 300 or more beds and those with separate departments of dental medicine were most likely to employ hygienists.
These professionals carry out many of the same tasks in hospitals that they provide in dental officeseducating patients about oral health and providing cleaning and other preventive care to medically compromised patients. For patients admitted with medical problems who develop dental problems during their hospital stay, hygienists may conduct a preliminary examination to identify the need for a dentist.
As in dental offices, dental assistants may be hired by hospitals to assist dentistsassuring that all necessary instruments and supplies are available, that the patient’s dental records are on hand and that infection control procedures are carried out; and assisting during actual procedures in the operating room. Their education involves a combination of course work (see chapter 1) and on-the-job training.
Hospital Hazards.
A hospital is no place for a sick person. This is the conclusion of many experts in the medical field, but what do you do when a hospital stay is absolutely necessary? It is impossible, of course, to surround yourself with an impervious safety shield, but smart consumers arm themselves with information about where these hazards lurk and try to gain admission to hospitals where hazards are kept to a minimum.
High on the list of hazardsif not at the topis the potential for acquiring an infection. The risk of such infections is even greater in the hospital than in your dentist’s office. Nosocomial is the name given to infections acquired during hospitalization; they are produced by microorganisms that dwell with relative impunity in hospitals or arrive on the coattails of new patients. Not present in patients on admission, nosocomial infections are costly and potentially dangerous “souvenirs” of a hospital stay.

Five to 10 percent of hospitalized patients acquire hospital infections annually. So what’s a concerned patient to do about these invisible invaders given that they are throughout the hospitalon the walls and floors, in the food and water, in transfused blood and intravenous fluids, perhaps even on the other bed in the room? The first line of defense comes when you’re hospital-shopping. Find a hospital that has a good nosocomial record. Ask if the following elements are in place:
ò At least one infection control nurse for every 250 beds
ò A trained infection control physician on staff
ò An active infection control committee meeting regularly
ò One or more staff members who belong to the Association for Practitioners in Infection Control
Hospitals that institute an infection control program can lower their infection rate by one-third, says a Centers for Disease Control and Prevention study.
A hospital knows its infection rate, although it may be unwilling to divulge it to you. Call the local department of health or ask your doctor/dentist for the rate in the postsurgical unit. If the hospital has an active infection-control program, it keeps its physicians informed about the current rate anyway. And if you must, don’t hesitate to call the hospital administrator.
Your Evaluation Visit.
There are a great many factors to take into account when you are evaluating a hospital to care for you during dental surgery or other medical needs. Just rememberthere is no way to know what a hospital is really like except by giving it a good once-over in personbefore you become a patient.
To get the most from an on-site visit, don’t just barge in, clipboard in hand and a scowl on your face. Call and ask to speak with the hospital’s administrator or someone in the community relations department. Explain that you are new in town and want to see the facility because you have heard so many wonderful things about it. Tell them you may have to have some dental surgery done soon, perhaps there, and you would like to get a feel for the place. Tell them anything you think will get you in.

You will probably get a quick walk-through (if that) with some minor-level administrative employee or a hospital volunteer by your side. He will point you in all the right directions, telling you very little. Another way to get information and more than a passing glance at the place is to visit a patient and ask about the food, nursing care and other features of the hospital experience that only a patient knows firsthand. Wander around a bit, as though you belong wherever you happen to be in the building at the moment. No matter how you tour, make sure to include the postsurgical unit and emergency room.
Where to go for Emergency Care
If you have ever awakened in the middle of the night with a throbbing toothache, you no doubt can sympathize with the millions of Americans who seek emergency care from their dentists, clinics and hospital emergency rooms each year. While few dental conditions are life-threatening, they are nevertheless often painful, interfere with eating and generally make the sufferer miserable.
True dental emergencies, according to the American Dental Association, include a broken jaw, broken teeth with the nerve exposed, a tooth that has been knocked out, gum abscess, cuts to the cheek, severe dental pain and infection, upper airway obstruction and uncontrolled bleeding. These conditions call for care as soon as possible. By evaluating your emergency options before you need them, you help ensure fast, competent, appropriate care.
Start with your dentist. During your get-acquainted visit, ask about her emergency services:
۱٫ Do you have a 24-hour answering service? How are nighttime/weekend calls handled?
۲٫ Typically, how quickly do you see patients with emergency needs?
۳٫ Do you have times set aside each day for emergency visits?
A 1991 study found that dentists had an average of 14.5 emergency visits per month. To accommodate these unscheduled visits, dentists use one of two systems.

The ER as Dentist’s Office
Hospital ERs are often used as outpatient clinics by families without access to private doctors or dentists. In one Seattle children’s hospital, for example, the number of dental emergency visits was more than twice as large in 1991 as in 1982, according to a study published in Pediatric Dentistry. Yet nearly 20 percent of the children who visited as the result of dental injuries required no treatment; during the 10-year period, only four injuries were serious enough to warrant hospitalization.
Such demands seriously affect a facility’s ability to provide true emergency care, can create long waits for everyone and can affect the quality of care for every patientyoung and oldin the emergency-care system.
Don’t be caught so unprepared that you are forced to use a crowded hospital ER when another resource would do. Instead, talk with your dentist about where to go and when to call her in an emergency. Look at alternatives to the ER in your community, such as walk-in dental centers.

in the morning and one in the afternoon during which emergency visits are scheduled. This system, often used in new practices with fewer regular patients, provides some reassurance that you will be seen promptly and with minimal waiting. Busier practices often prefer to “fit you in,” using cancellations or time when the dentist is waiting for anesthesia to take effect or the hygienist is with another patient. Such a system is a balancing act,calling for a skilled scheduling assistant/receptionist to prevent long waits or rushed care.
۴٫ Do you ever refer patients to the hospital for emergency care? Which one(s)? Why?
The authors of a Baltimore study published in the Journal of the American Dental Association in 1996 concluded that “hospital emergency departments are not the most appropriate setting for treatment whendental emergencies occur.” They point out that the care is costly and less likely to be definitive than that provided in dental offices. In fact, many community hospitals are not staffed or equipped to handle dental emergencies. Hospitals affiliated with dental schools and major medical centers are most likely to have dentists and dental residents on call at all times. However, even this doesn’t guarantee you’ll be seen by a dentist. The authors of the Baltimore study found that while the teaching hospital they examined had a fully staffed dentistry department, dental emergencies were rarely referred to it. Care, which primarily consisted of prescriptions for pain medication or antibiotics, was provided by the doctors in the emergency room.
There may be some occasions when you’ll have few options other than the emergency roomit’s midnight and the bleeding from an earlier extraction won’t stop; your daughter has just lost a tooth in a Sunday afternoon soccer game; you’ve developed a fever and swelling in your lower jaw while your dentist is out of town. So just in case, ask your dentist about hospital emergency care in your community. Then do some checking on your own.
A 1992 report on emergency care published in U.S. News & World Report suggests that you write to prospective hospitals’ quality-assurance representatives or emergency department chiefs and ask the following questions:
۱٫ What is the proportion of part-time (or moonlighting) doctors to full-time emergency physicians?
۲٫ What proportion of patients make an unplanned return visit for the same problem within 72 hours?
۳٫ How many times during the past three months has a discrepancy between an emergency room doctor’s reading of x-ray reports and a radiologist’s interpretations required a patient to return to see a specialist?
The written response should come back with low numbers in each case for the best overall emergency rooms.

In addition, when you tour and evaluate local hospitals, make sure you visit the emergency facilities and ask to talk with the department administrator or head nurse. Among the questions to ask are the following:
۱٫ Does the department’s staff include any or all of the following practitioners: emergency physician, oral and maxillofacial surgeon, periodontist, pediatric dentist, general dentist? Is there 24-hour coverage?
۲٫ Does the department have one or more trauma rooms, and is at least one equipped for dental care?
۳٫ How many dental emergencies are treated in the department each year?
۴٫ What is the nurse turnover rate (a clue to staff burnout and dissatisfaction)?
۵٫ Is a quality-assurance program in place to monitor how well the department cares for its patients?
۶٫ Are one or more social workers assigned to the department?
۷٫ Is two-way communication available with local ambulances?
Let’s return to the setting where most people receive their dental carethe dental office.



Before you go to dentist

Most of us associate dentists with the care of our teeth. We’ve undergone more than our share of oral examinations, complete with fairly regularly scheduled x-rays. We’ve probably had a few silver fillings, known as amalgams, and perhaps even a crown, a gold or ceramic covering for a fractured or seriously decayed tooth.
But the fact is that modern dentistry covers much more than “fixing teeth.” True, about half of all dental treatment relates to cariesbetter known to most of us as tooth decaybut during an oral examination, your dentist looks closely at your gums for signs of infection or other gum disease. Dentists are able to diagnose, treat and prevent diseases of the tongue, lining of your cheeks (mucosa), palate and jawbones, as well as the teeth and gums, and may spot the first signs of oral cancer. As we describe later, some dental specialists perform surgery to correct deformities in, or injuries to, the mouth or jaw. Other specialists apply braces to correct tooth alignment.
Modern dentistry has also expanded its knowledge of many topics, including anesthesia and other pain control, anatomy of the mouth, and surgical techniques. Unfortunately, though, great areas of knowledge lay untapped. Here’s a case in point.


Dental Implant in Iran


More than 20 years ago, research began on variations in medical practices, evaluating rates of use of various procedures and initiating considerable research on the outcome and effectiveness of recommended treatments. In dentistry, however, little similar research has been carried out. As a result, neither consumers nor dentists can know which treatment is best in a given situation. In 1995, University of North Carolina professors James D. Bader, D.D.S., M.P.H., and Daniel A. Shugars, D.D.S., Ph.D., M.P.H., reported in the Journal of Public Health Dentistry on their comprehensive review of the few studies that had been done on dentists’ clinical treatment decisions. Their conclusion? Variation in dentists’ clinical decisions was widespread. Here are some of the areas of disagreement and inconsistency that Bader and Shugars reported.
ò In a county in the South, the proportion of crown applications versus fillings for large cavities was three times greater than elsewhere in the survey.
ò When 700 North Carolina dentists taking part in a mailed questionnaire survey reviewed photographs of several teeth with worn spots or chips on the outer surface, 46 percent indicated they would work to restore the damaged teeth, while 47 percent said they would leave the teeth as they were. The remaining 7 percent would provide another treatment such as adjusting the patient’s bite.
ò A 1984 study asked more than 300 Washington State dentists to prepare treatment plans based on written descriptions of five elderly patients. The researchers found “substantial unexplained variation” in the plans for any given patient.
So what’s a consumer to do? Unfortunately, as Bader and Shugars point out, so little information describing outcomes of dental treatment is available that “the appropriateness of much of dental care cannot be assessed.” Thus, the wise dental consumer must ask questions, get a second and even third opinion before deciding on major treatments and evaluate the care based on previous experience, personal needs and a measure of gut feeling.
Without agreement on what’s “best” in dental care, you must also work to find a dentist you can trustone who involves you in planning your care, recognizes your desire to make truly informed decisions and works with you to keep your teeth without losing your life savings. Your Page 17
search for such a dentist begins with asking questions, getting several opinions and using your own knowledge, long before you actually visit a dentist.
Choosing your Dentist
Dentistry is a very up-close and personal service. You sit just inches away from the dentist with his fingers in your mouth for what may seem like an eternity. You may be fearful or anxious.
The first step in finding a dentist who has your health and comfort in mind is to put together a list of possible candidates.
Unfortunately, your choices may be limited by your geographic location. In 1993, there were at least 1,000 areas within the country that had been designated “dental health professional shortage areas,” including nearly 200 predominantly rural counties with no general or pediatric dentists at all. Only about 6 percent of the approximately 166,000 practicing dentists live in the western mountain region, comprised of Idaho, Montana, Wyoming, Nevada, Utah, Colorado, New Mexico and Arizona. Yet 18 percent practice in the three mid-Atlantic states of New York, Pennsylvania and New Jersey. California alone has 13 percent. If you live in an area with few dentists, you may have to be more creative and persistent in your search for a competent dentist. Use every one of the sources described below if necessary. But even if your choices are limited, take the time to carefully evaluate the dentist, the staff and the office.
As a starting point, you can refer to these resources for names of possible candidates.
ò American Dental Directory, an annual publication of the American Dental Association (ADA) that can be found in the reference section of many larger libraries. This directory lists ADA-member dentists (about 75 percent of all actively practicing dentists) with their educational backgrounds, certifications and office addresses. The American Dental Association does not provide telephone referrals, but instead directs callers to their local dental societies.
ò Your local dental society, listed in the telephone directory, which can give you the names and telephone numbers of member dentists who are currently taking new patients. The society may also provide information on training and specialty certification. In an emergency, many societies maintain a list of dentists who have agreed to be on call on a rotating basis to provide care.
ò Your dental managed care plan administrator. If you are covered by a dental health maintenance organization, preferred provider organization or other managed care plan, the plan maintains a list of participating dentists from which to choose, along with their education credentials, certifications and basic office information.
Your Options in Dental Plans
The availability of dental plans and dental benefits is a relatively new development for both dentists and consumers. Historically, dentistry was a “cash” businessmeaning that you went to the dentist, received a service and paid the fee on your way out. You selected the dentist of your choice and had the freedom to either return for further care or change dentists as you pleased. Very few consumers had any type of dental coverage and even fewer companies offered dental coverage to their employees.
According to a recent survey conducted by Human Resource Executive, however, the number of businesses offering dental benefits to their employees has reached 91 percent. Of the companies offering benefits, 38 percent offer a managed care plan.
There are four basic types of dental plans: direct reimbursement, indemnity insurance, dental preferred provider organization (PPO) and dental health maintenance organization (HMO). Any or all of these plans may have a managed care component that requires prior approval for some services.
ò Direct reimbursement plans. These plans are essentially cash plans because when you receive a service, you pay the dentist out of pocket and then are reimbursed by your employer or the plan’s administrator. Fees are usually discounted and your reimbursement is based on a percentage of those fees. You may incur either a copayment per service or a maximum out-of-pocket expense.
ò Indemnity insurance. The concept behind this type of plan is probably familiar to you since most insurance plans for the past 50 years have been based on it. In a nutshell, indemnity plans reimburse dentists according to a fee schedule or an allowance for some specialized services (such as crowns, braces and certain types of fillings). In order to receive a covered service, you must select a “participating” dentistmeaning that the dentist has a contract with the insurance company and agrees to accept the fee as payment in full.
ò Dental preferred provider organization. This type of plan introduces, for the first time, elements that not only affect the way dentists are selected, but also may influence treatment options. In a dental PPO, a group of dentists agree to discount their fees in return for patients being directed to them for all dental services. The thinking here is that each dentist in the group will gain additional patients, thereby increasing volume and eventually the bottom line.
In reality, if you’re in a dental PPO, you may find your choice of dentist severely restricted, and you may even need to change dentists if you want full coverage from the plan. While influencing treatment decisions is not a major goal of the dental PPO, there is still the concern that dentists may be reluctant to provide all treatment options if they feel the discounted fee is too low.
ò Dental health maintenance organization. The dental HMO is the most restrictive plan in terms of your selection of dentists. Dental HMOs have contracts with dentists to provide the care and services you require in exchange for a fixed monthly fee. This is called a capitation fee, and it literally means “paid on each head” for every member of the HMO. Typically, all of your care is covered 100 percent, although there may be a small copayment ranging from $5 to $10 for each visit.
In order to receive services, you must use a dentist in the HMO; if you go outside the plan, there is no coverage. Prior approval for certain types of dental services (crowns, braces and oral surgery) may also be required by the HMO.
For consumers, concerns must center on the quality of care and the competence of the plan’s dentists. The few studies that have compared managed care with traditional (fee-for-service) dentistry have shown no clear-cut quality differences. A 1990 study, for example, found that both fee-for-service and capitation programs were inconsistent in providing good dental care. A study of care for children in England and Scotland found that dentists in managed care plans provided more preventive care but let cavities get to a later stage of development before filling than did fee-for-service dentists.
Managed care dental plans generally provide basic information about the dentists in their plans. This probably includes education, specialty, any specialty certification and years in practice. While such information may be helpful, you still need to become actively involved in selecting your dentist.

all of your care is covered 100 percent, although there may be a small copayment ranging from $5 to $10 for each visit.
In order to receive services, you must use a dentist in the HMO; if you go outside the plan, there is no coverage. Prior approval for certain types of dental services (crowns, braces and oral surgery) may also be required by the HMO.
For consumers, concerns must center on the quality of care and the competence of the plan’s dentists. The few studies that have compared managed care with traditional (fee-for-service) dentistry have shown no clear-cut quality differences. A 1990 study, for example, found that both fee-for-service and capitation programs were inconsistent in providing good dental care. A study of care for children in England and Scotland found that dentists in managed care plans provided more preventive care but let cavities get to a later stage of development before filling than did fee-for-service dentists.
Managed care dental plans generally provide basic information about the dentists in their plans. This probably includes education, specialty, any specialty certification and years in practice. While such information may be helpful, you still need to become actively involved in selecting your dentist.
Some managed care plans actually encourage meetings between their dentists and prospective members. And if you aren’t satisfied with your first choice, make sure you know and understand the procedure for changing dentists.

ò Nearby dental schools, which may be able to provide the names of faculty members who maintain private practices, and hospitals with inpatient dental services, which may be able to give you the name of dentists with admitting privileges to the hospital (meaning they can send their patients there and care for them while they are hospitalized)
ò Your physician, especially if you have a medical condition such as diabetes that could complicate your dental careò Dental referral services, which are commercial agencies that provide referrals to dentists who pay for the service. Your choices will be restricted to dentists who participate, and the information you receive will be general, such as training, years in practice and office location. You can be assured, however, that the referred dentist is taking new patients. These services have toll-free numbers; you can find them in the toll-free telephone directory or your local Yellow Pages, or by calling the toll-free directory assistance line at 800-555-1212.
ò Newspaper advertisements, which historically merely announced a new practice, but which in recent years appear also for established practices. One type, the “advertorial,” looks like an article and provides information on dental health. The dentist’s name, office location and telephone number are usually given, which is one of the signals distinguishing this advertisement from a true newspaper article. As a resource, newspaper advertisements tell you a dentist is accepting new patients, but they don’t tell you why. The dentist may have recently graduated from dental school, moved to the area for the climate or relocated from another state after losing his license. You will have to find out more before entrusting your care to this dentist.
ò Yellow Page advertisements, which are paid for by the dentist. As with newspaper advertisements, dentists who advertise in the Yellow Pages signal their willingness to accept new patients. Because the information in the advertisement is provided by the dentist, you will need to verify all claims by careful questioning.
ò Friends, relatives and work associates, who are likely to be able to give you information on a dentist’s manner, policies and items such as office hours and availability of parking. This source may be less reliable in discussing the dentist’s education or professional competence.
If you’ll need a new dentist because of a planned relocation, ask your present dentist for a referral. Many have informal networks through school or affiliations with professional organizations. If your present dentist is retiring, he will also give you a referral to another local dentist. In either situation, you will still want to carry out your own evaluation, based on the information in the following sections. At least you’ll have a head start on your list of candidates.

Questions to Ask Yourself
Once you have the names and telephone numbers of several dentists, you’re ready to begin your evaluation. Start first, though, by asking yourself several questions. Your answers can help you focus on just what it is that you need and want from your dentist.
۱٫ Do I want ”one-stop” shopping with a general dentist who can provide most of my care or a specialist to handle a specific problem?
Dentistry is still dominated by generalists, rather than specialists. About eight in 10 dentists have trained as general practitioners. They offer preventive care such as cleanings, as well as treatments ranging from fillings to surgical removal of third molars, your wisdom teeth.
Unlike medical specialists, there are many fewer dental specialists, and referrals to designated specialists are much less common. Some procedures, such as orthodontics (correction of bite problems, for example with braces), are performed only by specialists. Others, such as periodontics (gum disease therapy), may be performed by a general dentist unless there are complications such as major infection, in which case you would be referred to a periodontist. You’ll find more about specialists later in this chapter.
Are there any firm guidelines for when specialty care is preferred over general care, or vice versa? Not much research has been done comparing the care given by specialists versus that of general dentists. In 1994, however, a report in the Journal of Oral and Maxillofacial Surgery described differences in recommendations for a patient with four wisdom teeth that had not erupted above the gum line. Eighty percent of oral surgeons who reviewed the case recommended surgery, whereas only 43 percent of the general dentists advised surgery.
The American Dental Association Code of Ethics requires certified specialists to practice their specialty exclusively, so even if you need a specialist for a specific condition, you will also need to have a general dentist for ongoing care.
۲٫ Do I want a solo practitioner or a group of dentists?
More than two out of three dentists are solo practitioners, so finding one may be easier than locating a group practice. The typical solo practice includes the dentist and one or more chairside assistants. These assistants prepare the dental instruments, mix materials used in fillings and other procedures and work alongside the dentist in caring for patients. About 60 percent of solo dentists also employ one or more dental hygienists, who are trained and licensed to carry out basic examinations, cleanings, x-ray procedures and patient education. You’ll find more about the training and responsibilities of both assistants and hygienists later in this chapter.
Dental group practices tend to be small, with only two to three dentists on average. Only about 12 percent of private practice dentists work in groups with three or more dentists. Group practices are likely, however, to have larger staffs than solo dentists, with nine of 10 groups having two or more chairside assistants and seven of 10 having at least one dental hygienist.
Both practice types have potential advantages and disadvantages that may be important to you. With only one dentist and a small staff, the solo practice encourages a close dentist-patient relationship. You can’t be shuffled from dentist to dentist as might happen in a group.
The very qualities that make for a close relationship, however, also raise the potential for problems. With only one dentist, office hours may not be as convenient as you would like, nor may the office schedule be always able to accommodate yours. When the dentist is away or otherwise unavailable, your care must come from someone outside the practice whom you have never met. There are no professional colleagues whom your dentist can regularly consult, learn from or be challenged by.
If you are willing to be seen by any of the dentists in a group, you’re likely to find evening and weekend hours and 24-hour emergency coverage. In the best-run groups, the staff members share with each other what they learn from journals and conferences, helping to keep everyone current. Your dentist can call on a second pair of hands or eyes in case of an emergency or before making a recommendation. If you find a group that includes both general dentists and one or more specialists, you can stay with the same group for all your care.
On the other hand, the larger staff means you have more credentials and practice habits to evaluate and monitor. You must ask about the background of each dentist, hygienist and assistant before her hand goes into your mouth or he prepares to take x-rays.
You may find this task made more difficult by staff turnover. New dental graduates are joining groups as salaried dentistsnot as part owners of the practicein ever-increasing numbers. According to the American Association of Dental Schools, nearly one-third of seniors plan to take salaried jobs on graduation. Many will work long enough to pay off education loans and raise capital before leaving to open their own practices.
۳٫ Do I want a dentist who outlines a treatment plan with options from which to choose or one who makes the treatment decisions for me?
In a major review in the Journal of Dental Education of what is currently known about dental treatment variations and outcomes, University of North Carolina professors James D. Bader and Daniel A. Shugars wrote, “Most of dentistry’s day-to-day procedures are rendered in the absence of comprehensive knowledge of their expected results.” In other words, even the dentist probably doesn’t know what the long-term effects of treatment are. Bader and Shugars assert that dentists are poorly prepared to assess the validity of studies or to interpret statements of risk in selecting treatment alternatives.
Charles G. Widmer, D.D.S., and colleagues at Emory University’s Dental Research Center agree. In a California Dental Association Journal article, they wrote, “Most dentists are not given courses on statistics and scientific methodology in dental school,” leaving dentists unprepared to critically evaluate scientific research on treatments and other topics.
Despite these potential shortcomings, in order to give truly informed consent, you should be given a treatment plan that outlines the following: treatment alternatives, advantages and disadvantages of each alternative, risks of each, costs of each and the likely result of doing nothing.
۴٫ Do I want a dentist who is prevention oriented and who provides information about steps I can take at home to lessen the need for dental therapy?
Historically, dental education and licensing procedures emphasized technical skill in diagnosis and treatment. Dentists were evaluated on how well they filled a tooth or fitted a crown.

Within the past two decades, however, the consumer wellness focus has made itself felt within dentistry. Several schools have reorganized the patient-care portion of their training so that each student has an assigned group of patients to care for throughout the program. This patient-focused care more closely simulates private practice than did the previous system of assigning a patient on a first-come, first-served basis to any available student at every visit. The new system provides greater continuity of care and offers more opportunities for the student to apply prevention techniques, such as cleaning teeth and applying fluoride to prevent decay, and to give advice on at-home oral care.
Fluoride treatments, sealants and other developments that help prevent decay play a role in encouraging prevention efforts. As we detail later in this book, the 50-year history of water fluoridation, fluoride toothpastes and direct fluoride application to children’s teeth has been a major factor in decreasing levels of tooth decay, especially on the vertical (rather than chewing) surfaces of teeth. Sealants have a shorter history, but these plastic coatings appear to be effective when applied to the horizontal (chewing) surfaces of molars (the large back teeth).
Managed care is a third factor encouraging preventive dentistry. Health maintenance organizations, preferred provider organizations and other types of managed care plans pay for care that is provided by a preapproved list of dentists. These plans pay for preventive measures such as regular examinations and cleanings, thus encouraging patients to schedule them and dentists to perform them.
One signal that a practice is prevention oriented is the presence of a dental hygienist on staff. Your dentist shows his concern for prevention by providing brochures from the American Dental Association and other health organizations; health-oriented magazines; and models, videotapes and other oral hygiene training tools for children and adults.
۵٫ Do I have a medical condition that could affect my oral health or that requires special monitoring during dental care?
If you have diabetes, hemophilia, a transplanted organ, heart disease, asthma or any other chronic health condition, you are most likely aware of the complications that can arise during even relatively minor dental procedures.

For now, make sure to note any allergies, chronic conditions or recent illnesses and ask prospective dentists about their experience in caring for patients with similar conditions. According to studies by the Eastman Dental Center in Rochester, New York, dentists who completed an additional year of training after their four years of dental school (called a postdoctoral general dentistry program), instead of entering practice immediately on graduation, are more likely to treat patients with serious medical conditions or handicaps, to spend more time on the physical examination of their patients and to use medical laboratories more often.
۶٫ Do I have a strong preference for a dentist who is young versus old or female versus male?
While finding someone who is competent, willing to involve you in care decisions and concerned for your comfort is probably uppermost in your mind, you may have age or gender criteria that you want to consider. No recent studies have analyzed age- and gender-based differences in care, but we can tell you that only about 13 percent of actively practicing dentists are women.
۷٫ Are there special circumstances in my lifestyle that may affect my choice of dentist?
For instance, if your daily schedule is a whirl of work, family and community obligations, fitting dental appointments into your date book is one more challenge. Take a moment, when selecting your dentist, to consider some factors that could make scheduling a bit easier. For example, do you want a dental office that is:
ò Accessible from bus or other mass transportation?
ò Open early mornings, evenings and/or Saturdays?
ò Flexible about last-minute cancellations?
ò Located within a specified distance from your home or workplace?
۸٫ How do I plan to pay for care? Do I have access to dental insurance? What are its provisions for coverage? If I am a member of an HMO or other managed care plan, how does my choice of dentist affect coverage?

Approximately 60 percent of Americans age two and older are not covered by dental insurance or government assistance programs such as Medicaid. If you are uninsured or have very limited coverage, you will need to plan for paying for your care. This may mean finding a dentist who is willing to be paid in installments or by credit card.
Further, even if you are covered by dental insurance, you cannot assume that all dentists or procedures are included. Read your policy and know its primary features. If a dentist you are considering does not accept your insurance plan, you will have to pay the bill in full and then submit your claim for paymentwhich will probably not be the full amount.
If you participate in one of the several types of managed care plans, your choice of dentist may be restricted. The traditional HMO provides coverage as long as you use a dentist within the HMO network. In order to keep members in competitive markets, however, some HMOs now allow patients to receive care from dentists outside the network, but the patient pays a greater portion of the fees out of pocket. Preferred provider organizations offer a list of dentists from which to choose who have agreed to provide care either at a discounted price or with you paying a portion of the fee (copayment). If you choose a nonparticipating dentist, you pay the full charges for your treatment.
Of course, in the best of all worlds, financial considerations should not play a role in your choice of a dentist or your plans for treatment. In reality, the better informed you are about your eligibility for coverage, the better able you will be to maximize your benefits to get the care you need.
۹٫ If I changed dentists in the past, why did I do so? What will I want the new dentist to do differently?
Once you have established the various factors that are important to you, you can begin to evaluate the prospective dentists you have identified.
Questions to ask the Dental Receptionist
You’ll save time and money if you ask some questions on the telephone first, most of which can be answered by the receptionist. These questions are discussed below and included on the Dentist Information Worksheet (see Appendix). Make a copy and have it in front of you when you conduct both your initial telephone screening interview and your inperson visit. Attach each dentist’s business card after your visit for future use. Once you have completed the worksheet, you are in a better position to compare dentists, giving priority to the answers to those questions that are most important to you.
When you call, explain that you are a potential new patient and ask:
۱٫ Is the dentist taking new patients? If not, is there a waiting list? How long is it?
۲٫ Does the dentist schedule get-acquainted visits? If yes, how much time is available? How much does such a visit cost?
Plan to schedule a visit during which no procedures will be done; in fact, you don’t even have to sit in the dental chair. A get-acquainted visit gives you the opportunity to meet the dentist and staff, tour the office and get an overall impression before anyone pokes fingers in your mouth.
A face-to-face approachsimilar to the way that dental care is deliveredis really the only way to fully evaluate the dentist’s answers to your questions. You can detect signs of unease or defensiveness and observe how well the staff seems to work together. Of course, it’s also the only way to see the condition of the instruments and equipment to be used in your care.
Get-acquainted visits are likely to be more common in urban areas. There, competition for patients may be intense, and dentists find that get-acquainted visits are an effective marketing technique. Even if a dentist doesn’t routinely offer one, he may agree to if prompted, so be sure to ask. And if the receptionist says no, suggest that she confirm this with the dentist.
You may have only 15 minutes, so take the Dentist Information Worksheet (see Appendix) and any additional written questions with you to guide the interview. Expect to pay for the visit, as it will not be covered by insurance.
۳٫ Does the dentist limit the practice to a specialty? If so, is he board certified?
As we have indicated, specialization is much less common in dentistry than in medicine, with fewer than 20 percent of dentists practicing a specialty. The American Dental Association recognizes eight specialties:

Endodontists treat the inside of the teeth, primarily the soft pulp. Most commonly, they perform root canal treatment, including cleansing, sterilizing and filling the canal. While general dentists will often perform uncomplicated root canal therapy, a specialist is likely to carry out the procedure if the root is abscessed or the bone or other structures around the tooth could cause complications. If you need a crown placed on the tooth after the root canal, the endodontist will probably refer you to your general dentist who can complete the procedure.
ò Oral and maxillofacial surgery. These specialists extract teeth, as well as perform surgery on the mouth, jaws, chin and related muscles. While simple extractions can be performed by your general dentist, an oral surgeon will usually be called in if you have a medical condition that could complicate the surgery, a wisdom tooth that is impacted (imbedded in the bone under the gum) or a need for another specialized procedure. Jaw reconstruction, certain types of cosmetic facial surgery and similar procedures requiring surgical skill are also commonly performed by these specialists.
ò Oral pathology. Oral pathologists study tissue from the mouth and teeth to diagnose disease and recommend therapy. They commonly work in hospitals, laboratories and other institutions.
ò Orthodontics. Orthodontists correct malocclusion (misalignment of teeth) by applying braces to the teeth to slowly move them into the correct position. In the past, most of their patients were children and teenagers, but increasing numbers of adults are undergoing the procedure. Your general dentist can refer you to an orthodontist or you can choose your own. The course of treatment can last up to two years (or more in adults), is expensive and is seldom fully covered by insurance, so look for an orthodontist with both a compatible personality and financial flexibility.
ò Pediatric dentistry. Also known as pedodontics, this specialty treats children’s teeth. Pediatric dental training involves not only medical and dental issues, but also child psychology and development. Thus, children with behavioral problems that would prevent them from sitting quietly in a dental chair or children with disabilities or unusual dental problems are most likely to be referred to this specialist.

Periodontics. These specialists treat the gums and supporting bone around your teeth. They are most commonly called in to perform gum surgery, such as recontouring, tightening or grafting gum tissue.
ò Prosthodontics.Prosthodontists replace all or part of damaged or missing teeth with artificial teeth: caps, bridges and dentures. While general dentists also perform these procedures, these specialists care for the difficult cases beyond the scope of most general dentists’ training or experience.
ò Public health dentistry. These specialists set up community dental screenings and treatment programs, monitor trends in dental disease and carry out educational programs for dentists and the community at large.
As we describe in greater detail in the next section, the American Dental Association Code of Ethics specifies that dentists who promote themselves as specialists must have completed additional education beyond the four years of dental school and practice exclusively in their specialty. Sixteen states issue a separate license to specialists, who are also required to have a general dentistry license: Alaska, Arkansas, Idaho, Illinois, Kansas, Kentucky, Michigan, Minnesota, Mississippi, Missouri, Nevada, Oklahoma, Oregon, South Carolina, Tennessee and West Virginia.
While dental specialists are required to get a separate license in these states, they are not required to obtain board certification in any state. In fact, board certification is an additional step that only about one in three dental specialists takes. Each specialty has a national board, monitored by the Council on Dental Education of the American Dental Association. Dentists who have completed their advanced education and worked in their specialty for a specified number of years (this varies with the specialtysee page 45) can apply to take the certification examination. On successful completion, they become board certified.
Board certification is not an assurance of quality care. No studies have been carried out comparing certified and noncertified specialists. Certification does demonstrate that the dentist knew how to perform the procedures of his specialty at a specific moment and was willing to have that knowledge tested by an independent body. Certification also reflects the dentist’s interest in education beyond basic dental training.

۴٫ Who performs basic teeth cleaningthe dentist or a hygienist? If the hygienist, will the dentist do this if I request it?
As we’ve mentioned, most dentists practice without other dentists but not without staff. Hygienists work full- or part-time in 63 percent of dental offices. Some experts argue that because their education focuses on preventive techniques such as cleanings, dental hygienists are actually better trained than dentists to carry out these procedures.
Nevertheless, if you want the dentist to carry out all procedures on your mouth, say so up front. Don’t wait until you’re lying back in the dental chair.
۵٫ What are the office hours? Are exceptions made for emergencies?
۶٫ Does the dentist have a time set aside to receive and return patient telephone calls?
۷٫ Who covers for the dentist when he is ill or on vacation?
Dentists who practice with a partner or in a larger group of dentists can usually rely on these colleagues to care for their patients during an absence. However, the majority of dentists practice solo and so must arrange for another dentist to provide emergency care when they are away. You will want to assure yourself that the covering dentist is as qualified as your permanent dentist. Ideally, your dentist selected him based on knowledge of his work and satisfaction of his patients. However, the selection could also have been influenced by family or school ties or simple expediency. Evaluate the covering dentist for yourself.
۸٫ Does the dentist accept my dental insurance?

۹٫ Does the dentist have a published fee schedule?
The availability of a printed fee schedule, while uncommon, will be the easiest way to compare fees among your prospective dentists. If a fee schedule is not available, ask for the fee for two basic procedures: for example, an annual oral examination without x-rays and an amalgam restoration (a silver filling) on one surface of a permanent tooth.
Your choice of dentist should not be made exclusively on the basis of the ”lowest bidder.” Nevertheless, the chances are high that you will pay at least a portion of the charges from your own pocket, so you will probably want to consider fees as one factor in your overall decision-making process.
The Get-Acquainted Visit
You’re now ready for the all-important on-site visit. You will find it worth both the time and money to talk with the dentist and staff without the anxiety of a pending examination or procedure. The visit gives you an opportunity to note not only answers to your questions, but also your own impressions and feelings about the dentist’s overall demeanor and openness, qualities that can be difficult to discern over the telephone. You can observe the interplay between the dentist and his staff and between them and other patients.
The very act of scheduling a get-acquainted visit signals to the dentist and staff that you are an alert dental consumer. From the beginning, you identify yourself not as the patient submitting to whatever the dentist mandates, but as an informed person who will evaluate and choose from among options. If you have been a fearful dental patient in the past, you may also find that taking control and insisting on information allay many fears.
Bring a copy of the Dentist Information Worksheet (see Appendix) with you to guide your questioning and allow efficient note taking. Most questions need only brief answers and should be immediately answerable. You have a right to ask these questions. Note if the dentist becomes defensive, vague or nervous when answering.
Because most dentistry is performed in private offices with little or no oversight by government or accrediting agencies, your observations are critical. Focus on the setting, equipment and procedures, as well as the staff. Chapter 2 describes key features to look for in a well-run dental office, including emergency preparedness, infection control measures and x-ray safety. Observe the following:

۱٫ Is the reception area clean, well-lit and large enough to accommodate waiting patients and their families?
۲٫ Do people seem to wait a long time?
۳٫ Are you greeted promptly?
۴٫ Are you seen on time?
۵٫ Are current health-related reading materials available?
As you sit down with the dentist, confirm any of the answers given earlier by the receptionist about which you have doubts. In addition, this is the time to ask about the dentist’s training, experience and, perhaps most important, philosophy of care, with questions such as:
۱٫ When and where did you receive your dental training?
۲٫ Did you complete a general dentistry residency (see page 44)?
۳٫ How long have you been in practice? Have you ever practiced in another state?
۴٫ When does your current license to practice expire? Have you ever had your license suspended or revoked in this state or elsewhere?
۵٫ What procedures do you commonly perform?
Beware of the dentist who answers “Everything” to this last question. While specialization is much less common in dentistry than in medicine, you want to be wary of a general dentist who claims to commonly perform all procedures from fillings to oral surgery. Neither the dentist nor his assistants can keep their skills sharpened by carrying out an occasional surgery. Practice does make perfect.
۶٫ Have you had special training to carry out newer procedures such as implants? If so, how long was it and where did you receive it?
A lecture during a dental conference hardly constitutes training.

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۱٫ Is the reception area clean, well-lit and large enough to accommodate waiting patients and their families?
۲٫ Do people seem to wait a long time?
۳٫ Are you greeted promptly?
۴٫ Are you seen on time?
۵٫ Are current health-related reading materials available?
As you sit down with the dentist, confirm any of the answers given earlier by the receptionist about which you have doubts. In addition, this is the time to ask about the dentist’s training, experience and, perhaps most important, philosophy of care, with questions such as:
۱٫ When and where did you receive your dental training?
۲٫ Did you complete a general dentistry residency (see page 44)?
۳٫ How long have you been in practice? Have you ever practiced in another state?
۴٫ When does your current license to practice expire? Have you ever had your license suspended or revoked in this state or elsewhere?
۵٫ What procedures do you commonly perform?
Beware of the dentist who answers “Everything” to this last question. While specialization is much less common in dentistry than in medicine, you want to be wary of a general dentist who claims to commonly perform all procedures from fillings to oral surgery. Neither the dentist nor his assistants can keep their skills sharpened by carrying out an occasional surgery. Practice does make perfect.
۶٫ Have you had special training to carry out newer procedures such as implants? If so, how long was it and where did you receive it?
A lecture during a dental conference hardly constitutes training.
۷٫ How often do you and your staff attend conferences and continuing education workshops?
۸٫ Is your dental assistant certified ?

۹٫ Who performs x-ray examinations? If it’s someone other than the dentist, has she received formal training (see page 66)?
۱۰٫ Do you provide a written treatment plan? Does it include fees?
Making your Choice
Once you have visited all of your potential dentists, review your notes and the checklist.
۱٫ Does one dentist stand out in terms of his willingness to answer your questions?
۲٫ Do you sense a better relationship is possible with one dentist versus the others?
۳٫ Does one dentist’s philosophy of dental care match yours better than the others?
۴٫ Does one dentist meet all or most of the criteria that are most important to you such as evening appointments, acceptance of your insurance or participation in a group practice?
۵٫ Did one dentist’s staff make a better impression than the others?
If the answer to these questions is yes, you have cleared a major hurdle in establishing a satisfactory dentist-consumer relationship. It is a relationship based on an exchange of information, informed decision-making and mutual concern for your dental health. You may even enjoy going to the dentist!
Changing Dentists
Despite your care in selecting a dentist, you may at some point feel that a change may be necessaryor you may be forced by an employer switching to a dental managed care plan. For the dentist-consumer relationship to work, you must be able to trust in his work (not blindly, though) and feel that your best interests are being served. What are some of the circumstances that may signal a need to change dentists?

ò The dentist takes telephone calls and otherwise fails to give you undivided attention during treatment.
ò The dentist doesn’t listen when you describe symptoms or concerns.
ò The dentist is repeatedly behind schedule and his staff doesn’t call ahead to suggest rescheduling.
ò The dentist fails to describe your problem and suggest a treatment plan, including fees and the likely results of not undergoing treatment, so that you can make an informed decision regarding care.
ò The dentist doesn’t answer your questions or responds in a manner that you are unable to understand.
ò The dentist is offended by your request for a second opinion for a major procedure.
ò The office and equipment have become shabby or dirty or otherwise indicate a decline in standards.
ò The dentist is hard to reach, fails to return telephone calls and/or doesn’t arrange for office coverage during absences.
ò You feel uncomfortable by remarks or behavior on the part of the dentist or a staff member.
These are just a few of the scenarios that may start you thinking about a change. Of course, there are other personal concernsyou may wish to find a dentist closer to your home or place of employment, or one whose office hours accommodate your work schedule and so on. If you have had a previously satisfactory relationship with your dentist, you may want to discuss your current concerns before actually making a change. The dentist may appreciate learning about problems with the staff, for example, and will initiate changes that enable you to stay with him.
If the breach is a serious oneyou have been injured by the dentist’s work, for instanceyou may want to ask the local dental society for a peer review or grievance-resolution hearing (make sure that your dentist is a member of the local society) or file a formal complaint with your state dental licensing board.
According to the American Dental Association, “Every dental society has established a system to resolve the occasional disagreement about dental According to the American Dental Association, “Every dental society has established a system to resolve the occasional disagreement about dental treatment that a patient and a dentist have not been able to resolve themselves. A peer review committee consists of dentists (and sometimes laypersons) who volunteer their time and expertise to consider questions about the appropriateness or quality of care or, in certain circumstances, about the fees charged for dental treatment.”
After the written request for review is submitted to the state or local dental society, the request is reviewed for completeness and referred to an appropriate committee. A mediatora member of the committeecontacts all parties and attempts to reconcile the problem. There is also an appeal process in the event that, after mediation, any of the parties is not satisfied with the decision. Contact the American Dental Association (211 E. Chicago Ave., Chicago, IL 60611; 312-440-2500) or your local dental society for further details about dentistry’s dispute-resolution program.
Inside Dentistry
A studied evaluation process is an important first step to ensure many years of good dental care. But before you lay back in that dental chair, let’s look at what your new dentist had to do to be able to sit alongside you.
The Making of a Dentist
There are currently 55 dental schools in the United States. Applicants must have completed at least two years of college (74 percent of students entering in 1994 had a bachelor’s degree and 5 percent had master’s degrees or higher). They must also take the Dental Admission Test, a standardized test for all schools, and submit letters of recommendation.
The dental school program is four years long. During the first two years, students study:
ò Biology as it relates to the human body, its function and disease
ò Anatomy of the mouth and jaw
ò Diseases of the mouth
ò Basic principles of oral diagnosis and treatment, with practice on models of the mouth and teeth Toward the end of the second year, students may begin to treat patients in the school’s clinic, depending on the individual curriculum.

What Is Accreditation?
Early in their history, dental schools, like their medical counterparts, decided what they would teach, how long the course to become a dentist would be and what qualifications faculty had to have. Some of these schools graduated competent (for their day) practitioners; many did not.
Accreditation is one process the profession established to bring order to the chaos. It means that a school’s faculty, facilities and courses meet an agreed-upon set of minimal standards. Used in conjunction with national examinations and licensing laws, accreditation helps assure that all dentists have been taught the fundamentals and have practiced their skills under supervision, achieving at least a minimal level of competence.
Programs that educate general dentists, specialists, hygienists, assistants and laboratory technicians can apply for accreditation by the Commission on Dental Accreditation of the American Dental Association. The commission is a private organization that reviews a program’s curriculum and activities against a set of standards developed by the commission. Most of its 20 members are appointed by the American Dental Association, American Association of Dental Examiners, American Association of Dental Schools, dental specialty organizations, the American Dental Assistants Association, the American Dental Hygienists’ Association and the National Association of Dental Laboratories. The rest of the board consists of a dental student and two members from the general public.
The review process includes a site visit by a team of consultants trained to evaluate according to commission standards and knowledgeable in the area being evaluated. These comprehensive visits are made before a program graduates its first students and every seven years thereafter (five years for oral and maxillofacial surgery programs). In addition, to retain accreditation, programs must submit annual reports to the commission, which can call for a special site visit if significant changes have been made in a program.
The on-site visits include interviews with school administrators, faculty and students; review of patient records, curriculum descriptions and other documents; observations of patient care; and review of a self-study report that the program completed before the visit. At the end of the visit, the group gives an oral summary of its findings to the program’s administrators, followed by a written draft report. The report notes the program’s strengths and weaknesses and suggests ways to improve. After rebuttal by the school, the commission issues its decision: approval, for programs that meet or exceed the standards; conditional approval, indicating that a program has specific weaknesses in one or more basic areas, which can be corrected within two years; and provisional approval, for programs with a number of significant weaknesses. In such cases, the program has a year to demonstrate measurable improvement or risk loss of accreditation. The commission has been criticized for not immediately closing these programs but asserts that its goal is to improve the quality of education, not close programs.
Theoretically, applying for accreditation is a voluntary process. But since state licensing laws require that dentists and hygienists graduate from accredited schools, programs to train them have little choice.
The accreditation process assures that all programs are reviewed by an independent body and measured against a single set of standards. However, there is still considerable variation in dental education. One study found that of 22 dentists who had graduated from American dental schools between 1980 and 1990, one had never treated a child, and half of them had no experience administering sedatives, surgically removing a tooth or performing hospital-based emergency room or operating room dental care.The third and fourth years focus on applying the basic knowledge to actual patients. Students learn fundamental techniques of the following:
ò Oral surgery
ò Orthodontics
ò Pediatric dentistry
ò Endodontics
ò Restorative dentistry (fillings and artificial crowns)
ò Practice management
Most important, they work directly with patients in the school’s clinic, within an affiliated hospital and in community clinics operated by or affiliated with the dental school.
Dentists who have graduated from dental schools outside the United States and who want to practice in this country complete the third and fourth years of American dental school before becoming eligible to take the licensing examination.
During their schooling, dentists must take and pass two written National Dental Examinations, also known as National Boards. Part I, taken at the end of the second year of dental school, covers anatomy, biology, chemistry and other basic academic topics. Part II is given during the fourth year and covers topics related to dental patient care, such as how to diagnose and treat specific conditions based on case examples. Successfully passing these tests is one requirement for future state licensing.
On graduation, the students receive either the Doctor of Dental Medicine (D.M.D.) or Doctor of Dental Surgery (D.D.S.) degree, depending on the school they attend. About one-third grant the D.M.D. degree. According to the American Dental Association, D.M.D. and D.D.S. degrees are equivalent because all students are graduated from similar programs with identical accreditation requirements. In 1993, the Journal of the American Dental Association published an editorial advocating the creation of one degree. Florida already allows dentists licensed there to use either degree designation. The bottom line is that neither degree confers more dental training or better care.
The Licensing Process.
All states require dentists to be licensed in order to practice. Thirty-nine states participate in one of four regional examinations, administered by regional examining boards; the otherstates have individual licensing boards that give their own licensing examination. Most states with regional examinations also require dentists to take a written examination on individual state laws related to dental and medical practice.
Licensing examinations, also known as state board examinations, have two parts. Content varies by state or region, but the written portion tends to focus on laws, medical emergency procedures, diagnosis and treatment. The second part requires applicants to demonstrate their knowledge and skill by carrying out a specified procedure on an actual patient (supplied by the applicant).
To practice, then, a dentist must:
ò Pay a fee
ò Pass the state/regional licensing examinations
ò Pass the National Board examinations
ò Produce a dental school transcript and diploma
In some states, he must also:
ò Show evidence of “good moral character”
ò Present a current certificate in cardiopulmonary resuscitation (CPR)
ò Show evidence of malpractice insurance coverage
Having done all this, the dentist may now practice dentistryin the state issuing the license. If he wants to practice in another state, he may have to repeat the process. According to the American Student Dental Association, 12 states do not recognize a license from another stateAlabama, Arizona, California, Florida, Georgia, Hawaii, Mississippi, New Mexico, North Carolina, Oregon, Tennessee and Texas. (There’s no way to know whether this restriction is to protect “home-grown” dentists from competition, a state’s citizens from less-prepared dentists or the state from “interference” from outside forces.)

Once licensed, dentists have several options. They can become employees of other dentists, clinics or HMOs. They can join the U.S. Public Health Service Corps, which is a federal government program that, among other things, provides medical and dental care to migrant workers, federal prisoners, Native Americans and other groups with little or no access to private health care. Another option, chosen by about ۲۰ percent of graduates today, is to go into practice alone or with a partner. Finally, about 36 percent of graduates will choose to continue their education, either in a specialty (11 percent) or with additional training in general dentistry (25 percent)
Continuing Their Education
While experience counts, you also want a dentist who keeps up with new procedures, research on causes of dental disease, and the newer studies on the effectiveness of traditional procedures. And this is where continuing education comes in.
Once in practice, a dentist may never again have anyone evaluate his skills or question his knowledge of the latest dental informationexcept an alert patient. Health law attorney Karen Guarino, R.N., J.D., in an article in the Journal of Dental Education, points out that the prevalence of one-dentist offices provides little day-to-day contact with colleagues. Peer oversight is also absent because relatively few dentists practice in hospitals, where peer review and quality assurance are systematic. Dental managed care programs are not yet widespread enough and so do not provide another level of oversight.
Once a dentist passes a state’s licensing examination, he is not subject to further examination unless he applies for a license in another state. Ten states require no continuing education for license renewal. And of those that do require evidence of continuing Page 41
۲۰ percent of graduates today, is to go into practice alone or with a partner. Finally, about 36 percent of graduates will choose to continue their education, either in a specialty (11 percent) or with additional training in general dentistry (25 percent)
Continuing Their Education
While experience counts, you also want a dentist who keeps up with new procedures, research on causes of dental disease, and the newer studies on the effectiveness of traditional procedures. And this is where continuing education comes in.
Once in practice, a dentist may never again have anyone evaluate his skills or question his knowledge of the latest dental informationexcept an alert patient. Health law attorney Karen Guarino, R.N., J.D., in an article in the Journal of Dental Education, points out that the prevalence of one-dentist offices provides little day-to-day contact with colleagues. Peer oversight is also absent because relatively few dentists practice in hospitals, where peer review and quality assurance are systematic. Dental managed care programs are not yet widespread enough and so do not provide another level of oversight.
Once a dentist passes a state’s licensing examination, he is not subject to further examination unless he applies for a license in another state. Ten states require no continuing education for license renewal. And of those that do require evidence of continuing education, most only ask that dentists acknowledge they’ve taken the required number of hours when they submit their license renewal form, subject to a random audit. The number of hours varies considerably from state to state, ranging from 12 to 25 per year.
So in your search for the right dentist for you, be sure to ask potential dentists about their efforts to stay current.

Dental Postgraduate Education.
As we described earlier, dentistry recognizes eight specialties. The American Dental Association Code of Ethics requires that a dentist complete an ADA-accredited specialty training program and practice that specialty exclusively in order to identify himself as a specialist. The length of the training varies by specialty: public health dentistry, endodontics, pediatric dentistry and periodontics are two-year programs; oral pathology and orthodontics are three years long; and specialists in oral and maxillofacial surgery and prosthodontics must complete four years of postgraduate education. Most programs are hospital-based and include dental care of hospitalized patients and clients in outpatient dental clinics, and time in laboratories and operating rooms, depending on the specialty. Instruction, which includes both lectures and patient care, goes beyond the introduction provided during undergraduate dental training and focuses on developing skills and knowledge in depth of topics within the specialty.
Postgraduate training for general dentists became formalized in 1972. The yearlong programs provide training in areas not fully covered during the busy undergraduate years, including use of sedatives, emergency medicine and anesthesiology. In addition, many of the programs emphasize the care of medically compromised patients such as those with heart disease, AIDS and other infectious diseases, diabetes and cancer, as well as physically and mentally handicapped patients. It is not considered another specialty, the way family practice has become in medicine.
The choice of completing a postgraduate year in general dentistry is entirely voluntary and is currently made by about 25 percent of dental school graduates. Individuals who enter the postgraduate general dentistry programs are generally those who ranked high in their undergraduate programs, according to Lawrence Meskin, D.D.S., editor of the Journal of the American Dental Association. Studies have found that practicing dentists who completed a postgraduate general dentistry program tended to spend more time caring for patients in hospitals and nursing homes, referred patients to specialists less often and prescribed fewer pain relievers and antibiotics than did general dentists who had entered practice right after dental school. However, the researchers did not evaluate the overall quality of care patients received by either type of dentist.
Relatively few general dentists choose to formally continue their education, so you are unlikely to find such a practitioner without a diligent search. A typical profile of a dentist who has completed a postgraduate general dentistry program might read something like this: He is most likely to have graduated from dental school since the early 1980s, when the size of many postgraduate programs significantly increased. He also probably has admitting privileges to a local hospital and teaches at a nearby dental school (both are potential referral resources).
What About Board Certification?
Certification plays a much less significant role for dental specialists than for most medical specialists. Once a dentist has successfully completed his specialty education, he can practice that specialty throughout his career without applying for board certification. Physicians, on the other hand, are pressured by hospitals and powerful managed care plans to become certified. Dental specialists in oral surgery and others who treat patients in hospitals may have to seek certification as a requirement for hospital admitting privileges. Furthermore, as managed care becomes more common in dentistry, the managed care companies will be pressuring specialists who want to be part of the company’s network to become certified.
To be eligible to take the certification examination, specialists must have not only the specialty education described above but also work experience: Oral surgeons and orthodontists must practice at least one year after completing their specialty education; endodontists, oral pathologists and pediatric dentists, two years; periodontists, three years; and public health dentists, four years. All applicants complete a written test. Oral pathologists must also demonstrate their skills at examining various tissues. All other specialties add oral questioning and a presentation of a patient’s case history. Certification for pediatric dentistry includes an examination of an actual patient.
Once certified, only specialists in oral and maxillofacial surgery, pediatric dentistry and prosthodontics must be recertified by examination at regular intervals. Otherwise, all that is required is to fill out a reregistration form and pay a fee each year. No specialty board has ever revoked a certificate.
Now let’s look at the other people we might expect to encounter in the dental setting.

The Other Players on Your Dental Health Team
The Typical dental office has three staff members in addition to the dentist to help care for you: a business office assistant, a dental (chairside) assistant and a hygienist. In the dental profession, these are commonly called auxiliaries. A large office with several dentists may have more than one chairside assistant or hygienist, as well as an office manager who oversees the day-to-day running of the business side of the office; a care coordinator who monitors patient scheduling and answers general patient questions about care; a bookkepper/records technician who handles billings and dental records; and possibly a laboratory technician who prepares bridges, dentures and other replacement teeth.
Office Assistants.
Office assistants typically answer the telephone, make appointments, handle billings and payments and help run the office. They may have completed a short commercial course in medical office management or have received on-the-job training. While their responsibilities don’t relate directly to the care you receive, they are nevertheless an important element in your overall comfort and confidence in the practice. A competent office assistant enables the dentist and hygienist to concentrate on your care; she can be depended on to remind you about appointments, to send recall notices and to assist you in arranging for installment payments.
Dental Assistants.
Dental assistants work chairside with the dentist in providing care. In testimony before the American Association of Dental Schools in late 1995, then-president-elect Jennifer Blake of the American Dental Assistant Association noted, ”Dental assistants are the only dental health care professionals delivering intraoral services to the public who are not mandated to satisfy certain educational requirements or to be credentialed.” Only five statesArkansas, California, Michigan, Minnesota and New Jerseyrequire that they register with the state in order to practice.
In fact, more than half are trained on the job by the dentists who employ them. Others will have completed a yearlong course in a commercial business school, junior or community college, and even a few dental schools.

Dental Supervision
Your state’s dental practice act specifies the duties that a dental hygienist or assistant can carry out under any of four levels of supervision by a dentist.
Direct supervision means that the dentist:
ò Personally authorized the procedure
ò Is in the office while the task is being carried out
ò Personally reviews the work before the patient leaves the office
Indirect supervision indicates that the dentist:
ò Has authorized the procedure based on his diagnosis
ò Is in the office while the task is being carried out
General supervision means that the dentist:
ò Has authorized the procedure based on his diagnosis
ò Does not have to be present while the delegated task is being performed
ò Remains legally responsible for the work and is expected to delegate only to qualified staff

Personal supervision refers to circumstances under which the hygienist/assistant assists the dentist as he carries out a procedure.

mission on Dental Accreditation of the American Dental Association, the same group that accredits dental schools. The curriculum of these accredited programs includes psychology, anatomy, nutrition, dental x-ray techniques, emergency procedures, ethics, office management and practice in assisting with patients.
A voluntary certification program requires current CPR certification and course work in radiation health and safety, infection control and general chairside topics such as applying topical (noninjected) anesthetics and removing excess cement after a crown has been installed.

State Dental Practice Acts
State dental practice acts are the set of laws governing the practice of dentistry in your state. They regulate the licensing and responsibilities of dentists and of dental auxiliaries, including hygienists, assistants and laboratory technicians. The act authorizes an administrative board, called the state board of dental examiners in most states. There are considerable variations among states in what is legally permitted or requiredfor example, one in three states has no education or examination requirements for a dental professional to be able to take x-rays. Consequently, you cannot assume that the laws are protecting your best interests. If you have any questions about licensing or what tasks can legally be performed, call your state board of dental examiners.

ing examinations and awards certification in four areas: Certified Dental Assistant, Certified Orthodontic Assistant, Certified Oral and Maxillofacial Surgery Assistant and Certified Dental Practice Management Assistant. Certified assistants must also complete 12 hours of approved continuing education each year to maintain their credentials. Of the estimated 200,000 dental assistants in the United states, about 29,000 have been certified by the board.
Certified or not, dental assistants work directly under the supervision of dentists and hygienists. Assistants are usually responsible for sterilizing instruments and following infection control protocols, as we describe in the next chapter. They also prepare the operatory (chairside area) for each patient, replacing disposable headrest covers, putting instruments on the dentist’s work tray, disinfecting work surfaces and performing any other related tasks. Depending on state law and the dentist’s delegation preferences, assistants may carry out various hands-on tasks such as mixing amalgam materials, Certified or not, dental assistants work directly under the supervision of dentists and hygienists. Assistants are usually responsible for sterilizing instruments and following infection control protocols, as we describe in the next chapter. They also prepare the operatory (chairside area) for each patient, replacing disposable headrest covers, putting instruments on the dentist’s work tray, disinfecting work surfaces and performing any other related tasks. Depending on state law and the dentist’s delegation preferences, assistants may carry out various hands-on tasks such as mixing amalgam materials, applying topical fluoride and removing a temporary tooth.

Dental Hygienists.
Most commonly, the functions performed by dental hygienists include teeth cleaning, nutrition counseling and patient education about home oral care. In recent years, states have revised their practice laws to allow hygienists a broader scope of practice. For example, 14 states now allow them to administer nitrous oxide anesthetic if the dentist is in the office. And all states permit them to carry out sealant application and root planingsome states require a dentist to be present during such procedures, and other do not.
What Your Hygienist Can Do
In general, the functions that hygienists can perform are those that are reversible. For example, they cannot drill a tooth to prepare it for an amalgam restoration (silver filling), but they can polish the amalgam once the dentist has put it into place. This list shows the functions that can be performed in at least one state. Those with an asterisk can be performed by hygienists in all states.
Perform prophylaxis*
Place sutures
Take x-rays*
Remove sutures
Administer local anesthesia
Apply cavity liners and bases
Administer topical anesthesia
Place temporary restorations

Apply fluoride*
Remove temporary restorations
Apply pit/fissure sealants*
Place amalgam restorations
Perform root planing*
Carve amalgam restorations
Perform soft tissue curettage
Finish amalgam restorations
Administer nitrous oxide
Polish amalgam restorations*
Take study cast impressions
Place periodontal dressing

Place and finish composite resin silicate restorations
Source: American Dental Hygienists’ Association.

At a minimum, hygienists are required to complete a two-year associate degree program at a college-level hygiene program accredited by the Commission on Dental Accreditation of the American Dental Association. Bachelor’s and master’s degree programs are also available, primarily to prepare hygienists to teach, conduct research and administer hygiene programs in large government and private dental clinics. The associate-degree curriculum includes both basic dental science courses and clinical experience treating patients under supervision. Graduates must pass a national board examination, earning the registered dental hygienist designation.
To receive a state license to practice, they must also pass a state or regional licensing examination that includes a written test and a clinical test on actual patients. Forty-two states, the District of Columbia and Puerto Rico also require hygienists to take accredited continuing education courses in order to earn license renewal.
The first dental hygienist was trained by a Connecticut dentist in 1906, primarily to perform cleanings and other preventive treatments. In the 1960s, the first experiments to significantly expand the duties of dental hygienists and assistants began. Most changes in state laws to allow additional responsibilities, however, have taken place within the past decade. Currently, 29 functions are legal in at least some states. Call your state board of dental examines (called a board of dentistry in some states) for details about your state laws.
Be aware, however, that studies have found that dentists often delegate functions without regard for state law. For example, nearly a quarter of dentists surveyed in Grand Rapids, Michigan, reported that they delegated pumice polishing (using a mild abrasive paste to remove teeth stains) to their dental assistants, despite the fact that Michigan law did not allow assistants to carry out the procedure. More important, perhaps, is the finding from studies in Kentucky and Washington State that the quality of the expanded functions performed by assistants and hygienists was closely related to the quality of the dentist’s work. So, while you want to ask about the training of assistants and hygienists who will help care for you, your primary concern must be for the supervising dentist, whose competency affects not only the care he provides but that of other team members as well.

Hygienists Go It Alone
In the late 1980s, California dental hygienists started an experiment to evaluate the benefits and risks of independent practices by hygienists. Thirty-four registered hygienists completed 118 hours of additional instruction and a 300-hour practicum in which they carried out expanded duties and responsibilities related to running a practice while employed by a dentist. Ten pilot practices were eventually set up across they state, some serving nursing home and other institutional clients, one offering services in clients’ homes, and the others in office settings. Among the services they provided were cleaning and preliminary examination, x-rays, topical fluoride applications and patient educationall without direct supervision by a dentist. Practices were evaluated by a team of dentists/evaluators before opening and twice annually to help protect patient health and safety.
These start-up hygienist practices had lower fees than did the dentists in the area for similar services. The hygienists were also more willing to take on Medicated patients than the dentists.
Several attempts were made during the early 1990s to pass legislation to enable these pilot practices and others to be established permanently in California. To date, these efforts have failed by slim margins. The pilot project was in its final stage by early 1997.
Several states, including Colorado and Washington State, have passed or are considering laws to allow independent practice by hygienists. These professionals cannot supply all of your dental care; a dentist must still carry out procedures under local or general anesthesia. However, an independent hygienist may be a viable alternative for patients who want to maintain basic preventive measures between major dental examinations, who live in underserved areas or who have circumstances that make a visit to a dentist’s office difficult (such as those who are homebound).

As we’ve said, dental care is a highly personal service, and finding the “right” dentist for you is an essential first step to getting quality care. But Where you get that care matters as well. In the next chapter, we help you evaluate the safety, appropriateness and convenience of your dentist’s office and other dental settings.



TMJ – Stress Induced, Stress Inducer

One of the main reasons for TMJ problems is stress and tension.

These simple exercises can be done in a few minutes each day. There are a variety of them, as there are many muscles affecting the jaw movement around the temporo-mandibular joint, and depending on which muscles are stressed or tense, one or other exercises will help. Goodman’s suggestion is to use only those exercises that provide relief and not those that cause more pain. This will vary from individual to individual.
These exercises are very similar to clinical orgonomic means of reducing tension, but can easily be done at home. What follows is a brief description, but I recommend you get the book if you have a real TMJ problem.

Basic Exercises

Mouth Exercises:
Reading Aloud – this involves holding a small cap from a plastic water bottle between the front teeth lightly and then reading aloud for a few minutes. The “sh” sound will not be possible, but this is not a problem as the reading serves to relax certain muscles to relieve built-up tension. This is done for a few minutes, but no more than five minutes each day.
Chewing – this involves the action of chewing without actually chewing anything. Again, start with a few minutes and then increase up to 5 minutes.



Throat Exercises:
Swallowing a Ball – if you imagine opening your throat as when you go to yawn, and then act as if you were going to swallow a ball, then this will work the muscles in the throat and neck. You don’t actually yawn, as this contracts the muscles. This is done half a dozen times or so a few times a day.
Ah! Surprise – this involves saying Ah! As if in surprise at a pleasant sight or event such as meeting a friend unexpectedly.
Imagined Inhaling – this uses the Ah! Sound with an imagined inhaling as if through the forehead, between the eyebrows. This draws energy up and further relaxes the muscles.
Imagined Gargling – this again uses the Ah! sounding exercise with an imagined gargling. Both this and the imagined inhaling are very good for stuffy noses or sinuses. This one must not be done too much as it can then overstress the muscles.
Imagined Laughing – this action, as if one were laughing, without actually laughing out loud helps to relax the larynx. It could be more aptly entitled “silent laughing.”

Tongue Rolling – roll your tongue around your mouth as if trying to clean your teeth. Do this in a gentle, relaxed way until you feel the tension or tiredness in the tongue muscles.
Tongue Stretching – this involves sticking your tongue out as far as possible, then inhaling as much as possible, then making the “eh” sound as you exhale. Repeat 8-10 times.
Ng-Ah! Sounds – the first sound tightens the tongue muscles at the back of the throat, and then the Ah! relaxes them. Do this for a minute or so.
Neck and Shoulder Exercises:
These involve moving the head and neck around in various ways to loosen tension. These are fairly familiar to most people.
Head Folding – moving head forward slowly all the way, then back all the way.
Head Rolling – rolling the head around slowly – both directions.
Shoulder Rolling – rolling shoulders as if in a circle – both directions.

Deep breathing using the abdominal muscles. This must not be done too often, and one must be careful not to get dizzy or light-headed.
Breathing gently through the mouth and nose.
In essence, anything that gets you to relax and release tension will help the TMJ situation. Stress and tension can also be related to tooth grinding at night.
Of course, addressing the source of the tension, often emotional in origin, will provide a deeper and more permanent solution for the problem.

Mercury Amalgam Fillings – The Shine is Off

The IAOMT has also written a guide to amalgam removal:
Safe Removal of Amalgam Fillings
A licensed practitioner must make up his or her own mind concerning specific treatment options.
Cut and chunk, keep it cool
Most of these suggestions are simple and obvious, common sense physical means of reducing exposure.  If you remove an old amalgam by slicing across it and dislodging big chunks, you will aerosolize less of the contents than if you grind it all away. If you keep it under a constant water spray while cutting, you will keep the temperature down, and reduce the vapor pressure within the mercury.

Your best tool for removing mercury vapor from the operating field is your high volume evacuation (HVE).  Keep it going next to the patient’s tooth until you are finished with the removal and clean-up process.  But check to see where in your office it discharges.  If the vacuum pump discharges into an open trap or through its own base, you could be pumping mercury vapor into your utility room or lab.
Rubber dam or no rubber dam?  Some dentists hate rubber dams, while others can’t live without them.  Reduced exposure amalgam removal can be done either way. A rubber dam will help contain the majority of the debris of amalgam grinding, among its many other benefits.  But you must know that mercury vapor will diffuse right through it, and some of the particulates will often sneak past it.
•  Always use a saliva ejector behind the dam to evacuate air that may contain mercury vapor.
•  Rinse the dam well as you go, because amalgam particles left on it will emit mercury from your garbage can.  (If you wipe your dirty mirror on a gauze square or the patient’s bib, that gray smear also emits quite a lot of mercury vapor!)
•  As soon as the amalgams are out, remove the dam and thoroughly rinse the  patient’s mouth before placing the new restorations. It can take as much as sixty seconds of rinsing to fully remove the mercury vapor. Search for gray particles. If there are particles on the back of the tongue, have the patient sit up and gargle them out.
If you don’t use a rubber dam, you must be vigilant with the HVE, and take frequent breaks to thoroughly rinse the field. Either way, the “Clean-Up” suction tip reduces the dispersion of particulates in the area.
Supplemental air
Provide the patient with piped in air, so they do not have to breathe the air directly over the mouth during amalgam removal.  A nitrous oxide nose hood, or a similar ventilation device, is probably more effective at isolating the incoming air than a nasal cannula.
Cover the skin
Covering the patient’s face with a barrier will prevent spattered amalgam particles from landing on the skin, or the eyes. The barrier can be as simple as a moist paper towel, or as elaborate as a surgical drape.
Maintain clean air in the operatory
Mercury vapor generated by removing amalgams disperses in the air of the operatory, leading to exposure of the doctor and staff. Beyond opening the window, here are some strategies for mitigating the problem:
Filtration:  A charcoal filter on your room air cleaner will help a bit.  More effective systems add negative ion generators to enhance the removal of metallic vapors. The “TactAir” is a stand-alone filtration unit that combines HEPA, charcoal and negative ion filters  (۹۰۵-۸۴۲-۲۵۷۳).  American Environmental Systems (303-449-3670) makes a negative ion system for industrial clean–rooms that can be unobtrusively installed, and left on all the time. Other sources and suppliers can be found on the Web.
Supplementary evacuation: Simply moving air away from the operative field can be effective in reducing mercury exposure, and some offices have installed creatively designed mechanisms.  One IAOMT member had the central vacuum cleaner in his office vented to the exterior of  the building. The patients hold the vacuum hose under their chins as he removes their amalgam fillings, resulting in zero mercury vapors detectable in the room.
Mercury filtration respirator: For added safety, the dentist and assistant can use a Bureau of Mines  certified mercury filtering respirator when grinding on amalgams.  The “MSM Comfo-II” model is available from the IAOMT office  for this purpose (863-420-6373).   The 3M company makes a charcoal filter dust mask that is also rated for mercury vapor.  It is available from many industrial supply sources.

Alternatives to Mercury Amalgam Fillings
Although the negative effects of mercury are by now well-known and increasingly accepted, the difficulty lies in finding a suitable replacement. Some of the early substitutes were found by us in homeopathic provings to produce the same or worse effects than mercury on health overall. Biological dentists will undertake compatibility testing to find the alternative filling that is least deleterious to your health. Of course, the best approach is always prevention, as well as the other, natural means of restoring tooth health, including remineralization.

Fluoridation: What You Don’t Know Could Kill You
The History of Water Fluoridation
Or How I Learned to Stop Worrying and Love My Teeth

There are two issues here: fluoride in toothpaste and fluoride in the public water supply. Both are based on the argument that fluoride is good for the teeth. It is true that small amounts of natural fluoride can be beneficial by strengthening the enamel, but given fluoride’s known toxicity and the very small margin, unlike most toxins, between a safe dose and a dangerous dose, as well as the widespread nature of fluoride in foods and the water supply, taking fluoride in any form is a risky business indeed. I grew up in a town with naturally fluoridated water, and most people in that community, myself included, suffered from dental fluorosis, mottling of the teeth, a sure outward sign of fluoride poisoning, and also weak and crumbling teeth. Although we ate a very healthy diet, with few processed foods, I was at the dentist continually until my early twenties, and have many fillings in my teeth (then done with mercury amalgam, or what they deceptively called silver amalgam fillings back then).
And to top it all, the fluoride being used in the water supply and toothpaste is not natural sodium fluoride, but a much more toxic waste product of the aluminum and fertilizer industries – ferro-salicylic acid, commonly used as a rat poison, and otherwise classified as a toxic waste that requires special and expensive procedures to dispose of.
Below I have given a brief outline of the history of selling fluoride as a safe, and indeed, even essential product for dental health, a sacred cow almost impossible to question. The Fluoride Action Network – http://www.fluoridealert.org – also contains a wealth of information on fluoride health effects and I would urge you to do your own research. If it is in your public water supply, it is almost impossible to eliminate however, and you may have to look at other water sources or seek to have your municipality stop adding it to the water supply everyone drinks from.
Adding it to the public water was done on the grounds that small children, who might not otherwise get access to fluoride (ignoring that almost all toothpastes have fluoride in them), would benefit. And it is only small children with growing teeth who benefit, if anyone does, but the solution is to have everyone ingest it regardless of dose, when the margin between safe and unsafe is sliver thin (1 part per million at most versus 1.5 parts per million).
Here is a list of communities that have stopped fluoridation of the public water supply since 1990 – http://www.fluoridealert.org/communities.aspx.  It is often surprising for most people to learn that most of the world, including Europe does not add fluoride to the water, and even in Canada and the U.S.A most of the public water supplies are not fluoridated despite decades of official support and promotion. There’s hope yet.

Some Historical Facts

Fluoride is one of the most abundant elements in the earth’s crust, but lies mostly deep underneath the soil.

Metals and mineral production brings up fluoride in large quantities. Industrial fluoride salts are a highly toxic waste product. Industrial fluoride waste was already a problem by 1850 and threatened to delay industrial growth.
Farmers were suing for damage to crops and livestock. Industry invented high smokestacks to disperse the fluoride into the upper air.
Then disaster struck.
۱۹۳۳: Belgium Meuse Valley Disaster – several thousand people became ill. Investigations placed blame on fluoride. Growing scientific and medical recognition of the toxicity of waste fluoride salts ran into the demands of war. Aluminum, a new industry and vital to the war effort, produced massive amounts of toxic fluoride waste.

Disinformation Campaign
Problem: growing mountains of toxic fluoride waste; increased emissions of fluoride into the air and soil. Fluoride was a crucial ingredient in the making of the atomic bomb, known as the Manhattan Project.
Military concerns over massive lawsuits coincided with industrial concerns.
Fluoride – a critical factor in the birth of the military-industrial complex.
Problem: threat of massive lawsuits. New Jersey farmers suffer damages to crops and livestock, and personal health downwind of the bomb factory.
Government is nervous/panicked about pending lawsuits in the light of the emerging “Cold War” with the Soviet Union, its former ally against Germany and Japan.
‘Solution’: turn fluoride from a toxic waste into a useful product.

Government would support the safety image of fluoride and the public, trusting the government, would accept the safety of fluoride waste.
Result: mobilization of the bureaucracy to fight the farmers and to support a “safe image” for fluoride.
Farmer’s efforts are stonewalled, small settlements are given and all evidence of harm from fluoride emissions is withheld as classified.

Fateful Decision
Historic moment: Proposal by an aluminum industry, ALCOA, funded scientist (not doctors or dentists) to add industry waste (fluorosilicates) to the public water supply.
Government and industry were worried about a flood of lawsuits following the end of the war and this proposal seemed the ideal solution. So the US government announced a “۱۵-year” study of two communities to see if the fluoridation of water was beneficial (using not natural fluoride, but the waste product from the aluminum industry – ferro-salycilic acid).

Fluoride and National Security – Program F
In the Public Interest?
Military concern led to Program F, conducted by the University Of Rochester, New York, Medical School.
Rochester had already been part of the Manhattan Project, studying the health effects of the “new materials” such as uranium, plutonium and fluoride needed for atomic bomb production.

Program F was not about children’s teeth but its main purpose was to furnish scientific ammunition that the government and its nuclear contractors could use to defeat lawsuits for human injury.
Its director was Harold C. Hodge, who had led the Manhattan Project investigation of alleged human injury in the New Jersey fluoride-pollution incident, a clear conflict of interest.
Much of the proof of fluoride’s safety rests on the work performed by Program F Scientists and Rochester emerged as the leading academic center for establishing the safety of fluoride, as well as its effectiveness in reducing tooth decay.

The Newburgh Study
Bomb-program scientists played a prominent role in the US’s first planned water fluoridation experiment, in Newburgh, New York. The Newburgh Demonstration Project is considered the most extensive study of the health effects of fluoridation, supplying much of the evidence that low doses are safe for children’s bones, and good for their teeth. The Chairman was Dr. Hodge.
The committee directed the type of medical studies and provided “expert advice”
Between 1945 and 1955 two studies were undertaken in tandem by the New York Department of Health, a public one and a secret one, the latter by Program F members.
The final report of the Newburgh Demonstration Project, published in 1956 in the Journal of the American Dental Association, concluded that “small

concentrations” of fluoride were safe for U.S.citizens.
The biological proof — “based on work performed … at the University of Rochester Atomic Energy Project” — was delivered by Dr. Hodge.

Information Suppressed?
The early study by Program F was completed and reported in the Journal of the American Dental Association in 1948.
The secret version: “most of the men had no teeth left.” The published version: “the men had fewer cavities.”

The secret version: “the men had to wear rubber boots because the fluoride fumes disintegrated the nails in their shoes.” The published version: “does not mention this.”
The secret version: “the fluoride may have acted similarly on the men’s teeth, contributing to their toothlessness.” The published version: “omits this statement.”
The published version: “the men were unusually healthy, judged from both a medical and dental point of view.” – Fluoride, Teeth and the Bomb

The transcript of one of the major secret scientific conferences of WW2–on “fluoride metabolism is apparently missing from the files of the U.S. National Archives even today (see Fluoride, Teeth and the Bomb).

Participants in the conference included key figures who promoted the safety of fluoride and water fluoridation to the public after the war – Harold Hodge of the Manhattan Project, David B. Ast of the Newburgh Project, and U.S. Public Health Service dentist, H.Trendley Dean, popularly known as the “father of fluoridation.”
“[T]he political pro-fluoridation stance has evolved into a dogmatic, authoritarian, essentially antiscientific posture, one that discourages open debate of scientific issues.” – Dr. Edward Groth, Senior Scientist, Consumers Union, 1991.

NTP Study
۱۹۷۷: U.S. Congress requested animal studies to determine if fluoride can cause cancer.
The result: an extensive animal study in the 1980s by the National Toxicology Program (NTP), published in 1990.
The principal finding: a dose-dependent increase in osteosarcoma (bone cancer) among the fluoride-treated male rats.
The NTP ruled that the cancer was NOT caused by the fluoride treatment.
Dr. William Marcus, Senior Scientist in the EPA’s Office of Drinking Water Policy examined the reports. He found that all the cancer cases had been “down-graded” in terms of causality due to fluoride.
“Now I’ve been in the toxicology business looking at studies of this nature for nearly 25 years and I’ve never seen that; never ever seen where every single endpoint that was a cancer endpoint had been down-graded. I’d seen one or two endpoints argued over, usually on a definition [of] what is a cancer in that particular tissue. But I’ve never seen every one of them down-graded. I found that very suspicious…” – recorded interview http://www.fluoridealert.org/health/cancer/ntp/marcus-interview.html .
Marcus went to Congress and a Congressional investigator found evidence that the scientists had been “coerced’ into altering their findings.

The Grand Alliance

Government interests (litigation protection and bomb making) and industry interests (litigation protection and money making) coincided on the fluoride issue.
A concerted effort was undertaken to add industrial fluoride waste (a recognized poison) to the nation’s water supply.
Six communities were already allowed to fluoridate, though studies were incomplete or showed harmful effects.
ALCOA litigation lawyer (Ewing) was appointed to the post that controlled the Public Health Service.  The PHS began a national water fluoridation campaign.
Over the next three years, 87 additional cities were fluoridated.
The control city for the 15-year study was also fluoridated, invalidating its results before the study was half-way over.
Fluoride was “sold” as healthy, American, and a public health need.

Masters of Spin
Heavy advertising/propaganda sold fluoride as the “child’s friend.”
Fluoridation was also made part of new government social welfare programs popular with many Americans.

Edward Bernays, nephew of Freud, and founder of “spin,” and author of the book Propaganda, led the campaign – “get the opinion-makers and the masses will follow.”

Aluminum waste went from a product of the dark, satanic mills, and only good as a rat poison, to promoter of friendly smiles and whiter teeth.


Homeopathic Medicine (A Kinder, Gentler Approach)

So far we have been considering the matter of correcting dietary imbalances, or using regimenal means to restore oral health. However, these measures will not be adequate to the extent that the dental or oral symptoms or conditions are caused by a particular disease. This can only be remedied with the right medicine. In our view, the right medicine uses the homeopathic approach, as disease is a bio-energetic degeneration that requires an energetic remedy, and the natural law of cure is the law of similars. 
This section presumes your basic understanding of disease and treatment using homeopathy – see our book Homeopathy at Home available from Amazon.com – Kindle).
There are excellent dynamic remedies that can be used to address various dental and oral health conditions. These medicines are commonly termed “homeopathic” medicines.
In complicated and chronic situations, where the dental problems are linked to many deeper and higher diseases, working with a qualified practitioner will be helpful and advisable where possible.


Dental Implant in Iran


Quick Guide to Treating Dental Issues

Silicea /Hepar sulph./Pyrogenium/Hypericum
Aconite/Gelsemium/Argentum nitricum 
Ferrum phos 
China off. if there is much loss of blood
Difficult Dentition
Generally, the following Tissue Salts – Calc. phos., Calc. fluor., and Silicea, but the entire series of twelve (usually sold as Bio XII) would be recommended to support the overall cellular functions involved.
Chamomilla where the child is restless, whiney, in pain, drooling and rejects what he asks for or rejects whatever is given to him.
Calcarea carbonica-ostrearum where problem is chronic and there is a persistent sour taste in the mouth.
Belladonna if there is a high fever, red cheeks and lips and intense irritability, with lack of thirst.
Drainage formulas are supplied by various homeopathic manufacturers.

Edema (swelling)
Acute: Apis/Histaminum
Chronic: Pulsatilla/Silica/Ledum
Osteoporotic Bone
Calcarea carbonica-ostrearum along with the tissue salts, Calc. phos./Calc. fluor./Silica 6x-12x.
Arnica before, then Arnica/Hypericum/Ledum/Nux vomica/Staphysagria after. Where bones are involved, such as in implants, or jaw surgery, you would add Ruta graveolens and Symphytum officinale.
Sensitive Teeth
This can occur often as part of the healing reaction, but may also present in the patient before treatment. One approach that has been found to be useful is the use of the tissue salts, as well as the needed emotional remedies for the given case at the time. 
Trismus (Lockjaw)
Hypericum and Ledum
Cuprum metallicum


Generally, in acute and first-aid situations you would:
√Use whatever potency you have on hand (6C, 12C, 30C and 200C are common in homeopathic remedy kits). Higher potencies work better in more acute situations. 
√Repeat the dose more frequently the more intense (acute) the situation. 
√A standard dose is to dissolve one or two tiny pellets or one drop of the stock remedy in about 4 oz. or 125 ml of water (preferably bottled) and stir briskly a few times or swirl around in your hand for a few seconds. 
√Repetition can be every few seconds in extreme cases as in anaphylactic shock, every few minutes in high fevers or every 15-30 minutes in most situations.

√The better the patient feels, the less frequently you will need to repeat the remedy.

Simple Solution: Buy a Home Remedy Kit

Some companies provide handy home-remedy kits to save much of the decision-making and also to cut down on costs. They usually involve pellets and in a given potency, such as 12C, 30C or 200C, and sometimes in 1M potency. Our experience is that the 200C or 1M are the ones to get. Start with a 200C and if you wish, add a 1M kit later. Often an accident or shock needs the higher potency to complete the treatment, as such traumas go deeper into the system and the higher potencies are able to penetrate the life energy levels more deeply.

The only other choice you need to make regarding purchasing a kit is the size, or the number of individual remedies in each kit. I would advise that you purchase at least a 50-60 remedy kit, but in any case purchase the largest one you can afford. 
You can start with a smaller one, and as you gain confidence and start treating more situations, you can always upgrade to a larger one. Sell or give your smaller kit to a friend and get him or her started on becoming a first-aid prescriber! See the section below for internet sources for buying home-remedy kits.

How Do I Dispense the Remedies?

When you provide a remedy, one or two pellets is equal to one dose. 
One or two drops of the liquid potency straight in the mouth constitutes one dose.


Promoting Dental Health

Vitamin D is most commonly understood to treat and prevent Rickets, a condition that results in severe limiting, softening and weakening of the bones. Thus, Vitamin D is critical to bone growth, density and strength. It helps to prevent tooth decay and build strong teeth. Periodontal ‘disease,’ that is inflammation and softening of the gums, leading to weaker teeth is also partly linked to deficiencies of Vitamin D. 
But Vitamin D is also a very important part of a healthy immune system, particularly in fighting off viruses, such as the common cold virus and various flu strains. Researchers now estimate that 60 to 100 per cent of North Americans are vitamin D-deficient, particularly those of us above the 42nd parallel, where winters are long, and our seasonal clothing exposes a scant five per cent of our skin to sunlight much of the year.


Dental Implant in Iran



For those living in temperate regions, and that is most of us, every year in the Fall and Winter we face the loss of access to the sun. The most important effect on our health from the shorter days is the loss of Vitamin D – the ‘Sunshine Vitamin.’ We have to get our Vitamin in other ways, as we can no longer rely on skin exposure to the sun to provide this essential and vital ingredient in our health.
In northern latitudes (above 51° latitude), in Spring, Summer and Fall, we can make vitamin D from exposure to sunlight (15 minutes, 2-3 times per week is all that is needed), but in the Winter we cannot make any. Below 35° latitude, Vitamin D can be made year round. Also, our modern lifestyle keeps us indoors more than used to be the case.  
The two main questions that arise are: 1. Where do I get Vitamin D?; and, 2. How much do I need?

What Type?
There are two main forms of Vitamin D: one in plants and one in animals.  
√Vitamin D2 is found in plants. 
√Vitamin D3 is found in animals. 
In mammals, including man, ultraviolet light converts a special form of cholesterol – 7-dehydrocholeterol – into cholecalciferol, the initial form of Vitamin D3. This form, however, is not active and needs to be converted in the liver and kidneys into calcitriol.  Because cholecalciferol does not qualify as the fully active form of Vitamin D3 in humans, it is often referred to as “provitamin D” (or “provitamin D3”). The “pro” in this word “provitamin” means the same thing as “preliminary form.”
We could take the natural plant form of Vitamin D, but it is far inferior to the animal derived Vitamin D.

Sources of Vitamin D

Concentrated food sources of Vitamin D include salmon, sardines, shrimp, milk, cod, and eggs. 
Sockeye Salmon are an exceptionally rich source of Vitamin D: a 4-ounce serving of baked or broiled Sockeye Salmon provides 739.37 IU of Vitamin D. The same 4-ounce serving of Chinook Salmon, another excellent source of Vitamin D, supplies 411 IU.
Many animal-based Vitamin D supplements containing cholecalciferol are derived from 7-dehydrocholesterol that was produced by the sebaceous glands in the skin of an animal (typically sheep) and then removed from the fur of the animal (typically raw sheep’s wool), and exposed to UVB (ultra-violet B) light that converts it into cholecalciferol.
In 1997, the National Academy of Sciences set Tolerable Upper Intake Levels (ULs) for Vitamin D as follows: infants, 0-12 months, 25 micrograms (1,000 IU) per day; children and adults, 50 micrograms (2,000 IU) per day; pregnant and lactating women, 50 micrograms (2,000 IU) per day.

There is some Vitamin D added to milk, but given the low levels (400 IU) and problems with pasteurized dairy products, this is not a good source to rely on. Most multivitamins contain only 200-400 IU.

Sun exposure is still the best. A person sunbathing can get 10-20,000 IU in 15 minutes (or only 10% of that if dark-skinned), and at that level, the liver will store it, and this is only good for about 30 days. But if you slather on the sun-block, you will also block the rays necessary to make Vitamin D. Again, the issue of sun and your health is one that deserves a book on its own, but take it from me that if you are healthy and eat healthily, including lots of essential fatty acids 3, 6 and 9, you will already have a natural sun protection from inside and won’t block the skin’s ability to make Vitamin D. 
Cod liver oil is another good source and also contains good levels of Vitamin A, which works synergistically with Vitamin D to promote bone growth and immune function.

Natural Versus Synthetic

Natural forms are always superior as they are easily and readily absorbed and utilized, whereas synthetic forms are irritating and at the levels recommended, or higher, can actually weaken or harm the system. The best source is cod liver oil and there are now many excellent brands available.
The key here is freshness; fresh cod liver oil has no fishy smell or taste – if it does, the product is indeed ‘fishy’ and should not be used as it has excessively oxidized. Most other products, such as D-Drops, will specify if they are from natural source. If not, they are generally synthetic.

Safety Issues

According to Sally Fallon at the Weston-Price Foundation: “Cod liver oil is probably one of the cleanest foods in the food supply. All cod liver oil goes through a complete filtering process, and repeated testing has shown that the amounts of mercury and PCBs in cod liver oil are undetectable. See the following link for an article on cod liver oil processing: http://westonaprice.org/modernfood/codliver-manufacture.html. 
Even without modern processing, mercury in cod liver oil is not a concern because mercury accumulates in the protein portion of fish, not in the oil.” The articles on cod liver oil on the Weston-Price Foundation site are generally worth reading.

For the first half of the 20th century, governments, doctors and health-care workers promoted daily ingestion by children and adults of cod liver oil, but in the modern drug era, this fell by the way-side, as it is not patentable and readily available at low cost. Instead, synthetic forms of Vitamin D were promoted, but these are rejected by the body and do little good and have the potential for harm. More recently, the use of cod liver oil has returned and there are very good versions available, made using modern techniques that avoid any oxidation (which produces that fishy taste and smell) and add natural flavors such as lemon or orange, that make them more palatable to kids in particular.

Vitamin C – Not Just for the Scurvy Few!

Vitamin C is most important for the health of the gums, to keep them firm and snug up against the teeth. Vitamin C is also an anti-oxidant that can help protect gum tissue from all the free-radical generating substances (usually toxins like chemicals and fluoride in food and toothpastes) we are exposed to (or choose to expose ourselves to –let’s not leave out personal responsibility!). Severe lack of Vitamin C leads to scurvy, which causes spongy, bleeding gums, weakness and a breakdown of the body’s connective tissue (and dentin, the inner layer of the tooth just under the enamel is mostly connective tissue). As Wikipedia says: 
Dentin is a mineralized connective tissue with an organic matrix of collagenous proteins. Dentin has microscopic channels, called dentinal tubules, which radiate outward through the dentin from the pulp cavity to the exterior cementum or enamel border.
Humans, unlike almost all mammals, don’t make their own Vitamin C. The problem is also that while fresh fruits and vegetables contain Vitamin C, this quickly disappears once the fruit is picked and also in vegetables with any kind of cooking. So, some supplementation with Vitamin C is necessary. Mostly what is available is ascorbic acid, a white powder. This is not really all of the Vitamin C, but more the outer shell. Nonetheless, it can still be useful.

Boost Your Vitamin C!
And it can also be made much more absorbable, as Dr. Judd, a PhD. in chemistry and dental health advocate recommends. 
Dr. Judd states to put 1 level tsp. (4g) of ascorbic acid in a glass, add ½ tsp. of our good friend baking soda, then one inch of water, let fizz, fill to 8 oz. and drink. This produces sodium ascorbate which he claims is 1000 times as soluble as ascorbic acid and thus a stronger immune booster and connective tissue builder. He recommends that you make this form of Vitamin C fresh daily and recommends against the dried ascorbates (buffered Cs) as they lose their effectiveness, not to mention they cost a lot more. Again, this is something you can do at home that is both more effective and cheaper. What’s not to like about that!
The advantage of this method is that the Vitamin C tastes pleasant, like pure soda water. You can also add some fruit juice of your choice to taste, but then need to follow this with a rinse afterwards.

Vitamin C Sources – Nature’s Powerhouses
Some natural and potent sources of Vitamin C (the whole vitamin):
Acerola (Malpihia glabra) or Barbadian Cherry is a shrub native to Central America and found throughout the Caribbean. Its fruits are orange-yellow to dark red and have a slight sour taste, resembling a lemon, but is suitable for individuals who have allergic reactions to citrus fruits. It contains an average of 1600-3000 mg Vitamin C per 100 g of fruit.

Rose hip (Rosa canina) is the fruit from a member of the rose family. Its fruits are usually orange to red in color and quite large. It is very common in many countries and the hips contain between 400 – 3000 mg / 100 g. 
Both plants are easy to plant in a home garden or as part of one’s (edible) landscaping, the first in warmer climes, the second more in temperate zones. While other fruits contain Vitamin C, these are the powerhouses of the Vitamin C world.

Benefits of High Doses
Regular high doses of Vitamin C are also necessary for optimum health in a general way as they cause the body over time to awaken dormant enzyme systems that can now utilize greater levels of nutrients more generally. On low doses of Vitamin C you avoid outward clinical signs of scurvy, but the body shuts these enzyme pathways down to preserve the small amount of Vitamin C in the body, and as a result other functions in the body are reduced, which also means that even if you are taking in lots of nutrients, your body is not properly utilizing them. (see Dr. Spreen, The Perfect Prescription for Your Teeth, p. 41).
One note of caution from Dr. Spreen: if you are planning on surgery under anesthesia, you need to slowly taper off the high doses until you reach zero just before surgery, as the high doses of Vitamin C will get rid of the anesthetic faster meaning the anesthesiologist will need to give you more than usual. But then immediately resume the doses after the surgery to help you recover.

Oil-Pulling – It’s a Russian Thing

No, we are not pulling your leg. A Dr. F. Karach, MD from Russia has found that unprocessed (cold-pressed, not the usual commercial varieties of) sunflower oil has the capacity to draw out the toxins in the gums like a poultice, as well as to stimulate the salivary glands to release predigestive enzymes. 
‘Oil-pulling’ also strengthens the gums and improves tooth growth and whitening. And finally, it strengthens your overall immune system to fight infection.
Where’s the catch you ask. It’s really quite simple, and again something you can do at home. You take one tablespoon in the mouth in the morning before breakfast (on an empty stomach) and slowly swish it back and forth which causes it to be drawn between the teeth. Do this for 15-20 minutes until the yellow oil becomes rather watery and whitish. Do NOT swallow this as it is toxic, but spit it out and rinse out your mouth several times with a warn solution of water with ½ tsp. of salt and ½ tsp. of baking soda. You can also brush your teeth with the solution.

Restoring Gums Naturally

One of the major issues people face is receding gums, bleeding gums, and inflamed gums to the point where the only solution that is proposed is surgical removal of the top layer of the gums, a lengthy, complicated, painful and very stressful procedure. 
Besides ‘oil-pulling’, another natural solution is the use of hydrogen peroxide and salt.
۱٫ Purchase diluted, pharmaceutical grade hydrogen peroxide and a new toothbrush (preferably small and narrow).
۲٫ At night, before going to bed, place some in a glass container, and using a new toothbrush, dip the brush in the peroxide and then press the brush firmly between the gums and teeth, dip again, then press the brush right beside the first spot, and repeat this covering the whole gum line. 
۳٫ Spit out the excess.
۴٫ Place a half teaspoon of sea salt or Himalayan salt in the palm of one hand, wet the index finger and press the salt against the gum line in one spot. Repeat this as you have done for the peroxide. 
۵٫ Spit out the excess and go to bed with the salt solution in your mouth.
This process will kill the bacteria and also work to firm up the gums. We have seen cases where 3-6 months of this has fully restored gums proposed for surgery to a natural pink color and firmness. This is a good procedure for severe, acute cases. Oil-pulling is a good thing to do daily to maintain health, both oral and general.


Cavities Can Be Good for You

Understanding the process of mineralization helps you to understand that cavities are part of the dynamic process of dental health.

With its more mechanistic approach, modern dentistry views the teeth as static and once a cavity is formed, it cannot be healed or repaired by the body itself. Dr. Price’s research, supported by others, has proven, however, that your teeth are alive and that they are constantly giving up and taking up minerals and nutrients. Part of this process involves cavities, which are, however, only temporary in a healthy person. 
Cavities are constantly being formed and refilled. When the natural mineralizing process is imbalanced, through poor diet, stress or deeper underlying disease states, then cavities will persist and enlarge. Most cavities can be corrected as part of the broader treatment process, though in some cases, due to their size or pain involved, they may need to be filled while the deeper factors that led to their formation and persistence in the first place are addressed. Again, dental health is part of and reflects overall health.


Dental Implant in Iran


Cavities are seen conventionally as a structural, and therefore a surgical, problem. When viewed dynamically, in the context of the living nature of our bodies, including the bone structure, teeth are themselves living organs that can respond to natural forces, both healthy and inimical. The message of a more dynamic approach to oral health is that cavities can be repaired non-surgically in most cases. This involves a process called re-mineralization. As one modern dentist has found, based on his and other research, almost everyone, even when healthy, has on the average about 20 cavities in their mouth at any given time as a natural part of the mineralization process (see the interview with Dr. Nara, Consumer Health Organization of Canada Consumer Health Newsletter, VOL. 8 Nos. 3 & 4 – April / May, 1987).
Most people face the problem of restoring damaged teeth and gums. The most important fact to remember is that such damage can, in most cases, be reversed. This is the experience of both Dr. Price and Dr. Nara. What this means is that as overall health improves, so does the health of teeth and gums. However, there are several things that you can do at the level of the teeth and gums that will assist the process.

In general, as Drs. Price and Nara have found, tooth brushing is not directly correlated with oral health. In fact, primitive people did not have toothbrushes, or even flossing material. In fact, when he visited his first group of people, in the Swiss Alps, he noticed they had teeth covered with a thin film of green slime, yet they had no tooth decay. Brushing and flossing may be done for other reasons, but they have little if anything to do with oral health and the prevention of cavities. 
If we do wish to brush, then we need to look at the way we brush and with what kind of toothpaste so as to at least not block re-mineralization and even help promote it. 
A chemist, Dr. Judd, has done extensive research and found that most toothpastes have two things wrong with them:
√They are either too abrasive, damaging the thin, hard outer layer of enamel.
√They contain glycerine, which is not easily washed away (it would take at least 20 rinses to do this!) and leaves a layer of film that prevents re-mineralization.
So, what to do? Brushing our teeth is an ingrained habit and we also like the clean feeling we get in our mouth from brushing. First, you need to give up the glycerine. This is what gives our teeth a squeaky-clean feeling, but this comes at a cost – glycerine acts like a layer of plastic that prevents your teeth from ‘breathing’, which is what mineralization is to teeth.
Almost all commercial and even natural toothpastes contain glycerine – it is either the first, second or third ingredient. Check the labels and you’ll be surprised. You might be lucky and find one that does not contain glycerine, and it will more than likely be a natural toothpaste made from baking soda (and sometimes salt as well). Baking soda is a good paste to brush your teeth clean with – it is not too abrasive and if you swallow it, is actually good for you, unlike commercial toothpastes with fluoride.

I’ll deal with the issue of fluoride and why it is not good for your health, dental or otherwise, in a separate section. 
So, short of some baking soda toothpastes that contain no glycerin (and no fluoride either!), you don’t have much choice. 
One other choice available for sale is a special formulation of pure soap that Dr. Nara has found works well to clean teeth and give that squeaky clean feeling, but not block mineralization. Yes, soap. Parents used to threaten naughty kids that they would wash their mouth out with soap if they used ‘dirty’ words. Now it seems this might actually be a good thing! The problem is the taste, of course, and the people making ToothSoap (www.ToothSoap.com) have provided natural flavors so the pure natural soap is more palatable. 
The only other option you have is to make your own toothpaste. This is quite easy actually – all you need is some pure baking soda (available everywhere and cheap to boot) and a little water. Just make up enough each time by putting a bit in the palm of your hand and picking it up with a wetted toothbrush, and you have the best and cheapest toothpaste in the world. 
Some people like to add a bit of salt, preferably sea salt or Himalayan salt, as these contain many necessary minerals lacking in plain table salt. Salt is also a natural toothpaste on its own, and further acts to fight dental plaque.
To make your own tooth powder (make into a paste as you need it), mix 3 parts baking soda with 1 part salt and store in a small glass container If you’d like, add a few drops of peppermint or wintergreen oil.
One way to avoid having to brush too often is to make a habit of rinsing your mouth out with pure water after every meal or snack. This washes away the processed sugars and other things that create acids that can damage teeth, as well as get converted into plaque. 
Transonic Wave Brushing

There is a type of toothbrush that emits transonic waves, which strip the fibria from microbes, so they cannot attach to the enamel of the tooth.  Two common units are from Braun and Sonicare.  If you decide to purchase one, make sure that it isn’t an ‘electric’ toothbrush, where the head simply rotates or moves back and forth.


How to Avoid Most Trips to the Dentist

Let’s face it – despite all the advances of modern dentistry, a trip to the dentist is one we would all rather avoid if possible. And it is possible. This book is intended to give you the knowledge you need to take care of your teeth and gums properly and also to use natural and homeopathic remedies should you still experience an oral health issue. 


Dental Implant in Iran


Between good oral hygiene and safe and effective homeopathic and other natural remedies, you can solve most of the issues people tend to go to the dentist for. You will not only gain peace of mind, but save yourself a lot of money in the bargain. And this is not rocket science, but just a lot of common sense and simple first-aid.
It is strange that they call it common sense, as it seems to be anything but common. What you will learn here is not taught to dentists at dental school, yet comes from dentists themselves, and it goes against most of what you have been told about dental health from so-called dental health experts. Maybe it is called common sense because it is the sense that you don’t find with so-called experts!

In MediZine, v.6 #2, April, 2000, the American Dental Association states that there is a dental ‘epidemic’ with 42% of those over 65 and 24% of those over 44 years of age no longer having any natural teeth. This does not take into account all those who have had some teeth pulled and replaced, nor those with cavity-filled teeth, or with root-canals. As Mother Earth News reports, the ADA’s own figures show that the average American has 14 teeth decayed, filled or missing by the age of 20. (http://www.motherearthnews.com/Nature-Community/1979-03-01/Dr-Robet-Nara.aspx) 
And if our teeth are ailing it is also the rest of our body that is affected. Good oral health is a key to good general health. So, what you do to help your teeth and gums will go a long way to making you healthier overall. 
There is a whole new type of dentistry emerging, called ‘biological dentistry’, that recognizes the important link between dental health and overall health, as well as the negative effects on both teeth and the body generally, of fluoride, silver/mercury amalgam fillings, and root canals. More information on finding a biological dentist is at the end of this book, but our goal here is to minimize, if not eventually eliminate, trips to the dentist. 
Let’s face it – a dentist is essentially a specialist surgeon by training, a person who fixes in the mouth what is broken and can’t be repaired by the body itself. But the body can repair most things if you give it the proper tools and conditions, and trips to the dentist, preferably a holistic or biological dentist, will be few and far between. And prevention, in this case, begins at home. It really is true in this case that ‘an ounce of prevention is worth a pound of cure’.

Understanding Your Teeth
Our Best Friends/Worst Enemies

Our teeth are our best friends, but when they aren’t healthy, they become a major pain. The main problem we have with our teeth is that they get large cavities, crack and break, or get inflamed at the roots, all of which can produce unbearable pain. Even if the pain is manageable, these problems often make it difficult if not impossible for us to eat. 
Therein lies the nub of the issue: there is a direct and critical link between the health of our teeth (and gums) – our oral health – and the health of the rest of our body (and mind). And it should be no surprise if I tell you that the critical factor in the health of both your teeth and your body generally is proper nutrition. In many ways, we become what we eat.

The Foundation of Oral Health: Your Teeth and Your Diet

The pioneer in exploring the link between health and diet, and in particular, between diet and healthy teeth was Dr. Weston Price, trained as both a doctor and dentist. By the early 20th century the birth of food as an industrial rather than agricultural activity – through food processing and chemical additives – had radically changed the way Americans ate.

It also brought increasing dental problems. Dr. Price suspected a link between a diet increasingly stripped of vital nutrients through mechanical and chemical processing and the decrease in dental health he observed in his practice. 
In the 1930s, he decided to make a series of trips to different parts of the world where he could study traditional peoples, both who had remained faithful to their traditional diet as well as those who had adopted a more modern diet. 

Your Teeth Are Alive – The Process of Mineralization

The reason that proper diet and nutrition can not only prevent dental decay, but also restore dental health is that the teeth are actually ‘alive’. Contrary to the conventional view of the teeth as inert, the teeth are constantly changing through a process called mineralization, and this process is vitally affected, for better or for worse, by what you put in your mouth.

Mineralization is the natural process in which your teeth constantly renew themselves by giving up minerals and taking on minerals from the saliva. It is like a renovation. Old material needs to be taken out and replaced with new, creating a stronger structure. Mineralization affects the tooth enamel, the outer hard part of the tooth.
Let’s take a quick look at the tooth structure. 
The following diagram is taken from Wikipedia. The enamel is what protects the sensitive inside of your tooth, with the nerves and blood supply, from the harsh outer environment, and also makes it possible to chew food.

So, you actually can do a lot to help keep your enamel healthy, not just by avoiding things that are harmful, but more positively, doing those things that actually help the re-mineralization, that is, renewal of your tooth enamel. 
Taking mineral supplements, which are carried to the body through the blood supply, has little or no impact on the re-mineralization of the teeth. Why? Mineralization takes place on the surface of the tooth and there is no connection between the blood supply to the tooth and the enamel. 
Instead, your body has a natural process to promote mineralization. This process involves using acids to dissolve mineral molecules so they can be made useful in the form of ions. However, acids can also pose a problem for the teeth, so the body came up with a simple, yet elegant solution. It takes carbon dioxide (CO2) from the air we breathe and water from our saliva to create carbonic acid, a mild, unstable acid. 
Carbonic acid does the job. It dissolves the minerals in the food we eat so they can be used to build new enamel, as well as to carry away unwanted minerals. It also quickly goes back to its constituent parts – CO2 and water. 
There are several things that need to happen for the mineralization process to occur as nature intended:
۱٫ There must be sufficient minerals in the saliva (from foods).
۲٫ There must be carbonic acid (from breath and saliva).
۳٫ The tooth enamel must be clear and not blocked so that the mineral ions dissolved in the carbonic acid of the saliva can adhere.
۴٫ The carbonic acid must go back to water and carbon dioxide gas so that the mineral ion can precipitate out to be used by the tooth to fill any ‘holes’.
At this point we should go back to Dr. Price to understand the difference between natural, organic acids found in foods and synthetic acids found in processed foods. You also need to understand the difference between the natural acids necessary for good tooth health and the warnings you often hear about not eating acid foods, based on various charts concerning acid and alkaline foods.

Acids and Teeth

One of the concerns you often hear is that it is the acid in food that is responsible for dental decay and plague. Dr. Weston Price demonstrated that the problem did not lie in the acid nature of food in a paper he delivered to a gathering of dentists almost 90 years ago. It has a long title, and was largely forgotten in the capture of medicine by the pharmaceutical industry shortly thereafter. But it bears repeating here. Acid-Base Balance of Diets Which Produce Immunity to Dental Caries Among the South Sea Islanders and Other Primitive Races by Weston A. Price, DDS, MS, FACD. Read before the New York Dental Centennial Meeting, New York, N.Y., December 4, 1934; reprinted from the Dental Cosmos for September 1935.
In this paper, Dr. Price provided the following statistics on dental caries (cavities) per 1,000 teeth examined:
Figure 1: Dental Caries on Primitive and Modern Food
People Primitive Modern
Alps 46 298
Hebrides 11 300
Eskimos 0.9 130
Indians 1.6 215
South Sea Islanders 3.4 308
He then showed that the natural, primitive diets were higher in acids for four out of the five groups. 
Dr. Price felt that something else was responsible, and he pointed to the mineral and enzymatic content of foods as being more important than the pH or acid-alkaline levels.
From his study of primitive peoples who went from almost no dental problems to significant levels of decay and cavities, not to mention structural

distortions, Dr. Price found that the diets, despite their variations, had a common denominator, namely the “chemical and activator [enzyme] content” was relatively equivalent. 
Dr. Price realized that it was not possible for modern man to go back to eating a primitive diet, but found that the equivalence in mineral and activator content could be achieved by eating whole grains, vegetables, fat-soluble activators such as butter (organic and from grass-fed cows), along with the organs of animals and the use of sea foods. In addition, it was necessary to reduce sugars and sweets in refined form.

Thus, the problem was not acidity per se, but food value, which provided an over immunity to disease generally, in terms of nutrients and enzymes. Enzymes are necessary for all body metabolism and functions. Processing destroys enzymes as well as many nutrients. 
It is processed foods and their acid content that creates problems for tooth enamel, not to mention the strong acids used in beverages, and created by processed sugars such as high-fructose corn syrup, and artificial sweeteners.

Promoting Mineralization
Let’s summarize what we have said so far:
۱٫ Teeth are living tissue.
۲٫ The enamel of teeth is dependent on minerals in the saliva, not the rest of the body.
۳٫ The body needs organic acid in the mouth for certain chemical processes, but acids in processed foods and drinks attack tooth enamel.

۴٫ Healthy enamel is dependent on a natural balance between the loss of minerals due to acids and the restoration of enamel due to the action of enzymes and other factors present in whole foods. 
۵٫ There is an important distinction between natural acids and acids formed as a result of the food processing industry (refined sugars, essentially). 
۶٫ The prevalent intake of refined and processed foods, in particular sugar, means that the process of mineral loss heavily outweighs the process of mineral restoration.
Thus, we can see a firm link between a healthy diet and healthy teeth, as documented by Dr. Price over 70 years ago. 
A proper diet is the foundation on which all health, including that of the teeth and gums, must be based. A proper diet, one rich in minerals and enzymes, allows the process of mineralization (de- and re-mineralization) of teeth to occur at a natural rate. 
As regards the issue of vegetarianism, this is beyond the scope of this book, but I would note that Dr. Price found that fat soluble factors found in animal fats were important to dental health.
Another factor to consider is that phosphorus, which is important to dental health, is not generally found in plants and fruits. Phosphorus is mainly found in the protein food groups of meat, fish or dairy. If you eat adequate amounts of protein you generally receive an adequate amount of phosphorus. Although whole-grains contain phosphorus, this is a storage form of phosphorus called phytin, which is not absorbed by humans. Fruits and vegetables contain only small amounts of phosphorus.