Common Sense is NOT so Common

Before reading this or deciding this is a boring and lengthy blog that you have no interest in, I have a suggestion. Skip to the very last paragraph then decide if you wish to read the entire article.

 

I could get into a discussion about many things that we do not always take the most sensible path – driving, eating, the way our government operates, etc. but here I am going to focus on protection against diseases.

 

In general humans have come a long way since we have invented the microscope, antibiotics, disinfectants for home, industrial and medical use, disposable gloves and other protective barriers. You would think that all the research and education would have produced some very good habits among us all at work or home. Ironically, however, the CDC (Center for Disease Control) call their protocol Universal precautions. As I will point out there is a wide range of understanding and compliance even among all of us health care professionals. That being the case, how can we expect average people at home and workers in all other fields to do what is right if we are not setting a great example.

 

In my observation I believe there are two major deterrents to actually developing universal precautions. One is that we have two major organizations that govern the health care professions and some other industries. One is the CDC and the other is OSHA. Neither of these important organizations disperses any false information. The problem is how some or many workers interpret their manuals. What we all should be aiming to do is to protect everyone all the time to the best of our ability. Sadly many show the greatest amount of effort to protect themselves and not enough toward protecting the patients – both current and subsequent and also their co-workers. I believe some of their habits are a potential threat to themselves. I believe this is attributed to having a false sense of security that many have when wearing disposable gloves.

 

I have been a Dentist for 40 years. Therefore I have been in the profession throughout several major transitions. Aside from the changes in procedures  – from  amalgams to composites, only dentures to the alternative of implants and many advances that have allowed higher levels of esthetics, longevity and efficiency through technology there have been a few monumental changes in infection control. Before 1986 we would do the following:

Wear gloves only when performing a surgical procedure or on any procedure when a patient was known to have been exposed to Hepatitis or Tuberculosis.

We wore masks for those and also if either the patient or we had a cold.

Surgical and Root Canal Instruments were steam sterilized. General instruments were soaked in a Gluteraldehyde solution. Equipment and surfaces were wiped with alcohol.

 

Once we learned about HIV – AIDS we went through very major changes. We began wearing gloves for all procedures for every patient. We began using more disposable items, steam sterilizing all types of instruments and more advanced chemicals for surface wiping. In addition to HIV there have also been new threats such as several other forms  of Hepatitis and Ebola. The focus on prevention also lead to further research on bacteria and viruses, parasites in our water lines. This is another topic I will address at a future date.   

 

The scare about HIV – AIDS created a very different approach than before. While we previously only wore gloves and other precautions when we were aware of hepatitis history or were experiencing cold or flu now the rules became” Treat every patient as a possible HIV contamination” . We therefore changed our regimen even for the very simplest procedures and even on family members. We certainly would use a different approach at home when being intimate with a lover or caring for a child and overlooking their flaws involving saliva or any other bodily fluid. However, for a routine exam or any treatment procedure in an office we would use those universal precautions to prevent contamination when we were 100% certain that person was not a carrier.

 

So now let us go back in time to pre 1985. This is what we were taught. When it was deemed necessary to wear gloves we first washed our hands then carefully placed the gloves. From that point we were careful to avoid touching unsterile items with the one exception being the necessary steps in treatment. When treatment was completed we carefully removed the gloves, carefully disposed of them and again washed our hands.

 

Somehow we have strayed far from that recipe. I would assume that it is still being used by surgeons in hospital operating rooms.. The rest of us have wandered far from sensible and effective and responsible actions.

 

In addition to practicing a wide range of general dentistry for the past 40 years, I have also been a patient at various dental and other medical offices and I have attended many continuing education classes. From all these encounters and also from my own office experience – trial and error, observing other dentists, Hygienists and dental assistants. I learned from those who were employed by me for over 10 years as well as those I interviewed or had for very temporary employment. I also learned from observing and being treated by Medical Doctors, nurses and medical Assistants. When I saw something good and impressive I altered my habits to mimic theirs. When I saw poor habits I made every effort to avoid repeating. Sometimes these were simply a matter of incomplete knowledge while other times it was purely being careless. Sometimes I believe that we mean well but are confused. We may have been taught proper protocol but then get caught up with the factor of time. Therefore we cut corners. We do not wash hands often. We touch multiple items some of which never should be contacted with gloved hands since they cannot be feasibly disinfected.

 

I believe that part of our confusion may stem from shows and advertising on television and magazines. Even our own professional journals and webinar classes will show dental professionals engaging in controversial behavior. One example I have often seen is the use of gloves when touching a computer keyboard or mouse. Another is when using a camera (not intraoral) but regular camera taking photos of a patient’s face. There really is no feasible way to disinfect your camera or computer. Chemicals will likely cause at least sticking of parts if not rusting and deterioration. Part of the confusion comes from crime investigation. Crime investigators wear gloves for two reasons – to avoid contamination and also to prevent placing their own finger prints. In order to end that confusion they really should separate their duties – like we should separate ours. Gloves should never be worn for taking photographs or using a computer, taking notes and many other tasks. Just put the gloves on when you are going to  contact contaminated areas. Once you are gloved touch only what is necessary and what can be sterilized, disinfected readily or disposed. Keep it simple. Keep it safe.

 

So here now is my current protocol I use in my dental practice and train my staff.

 

1. Wash hands before preparing for procedures
2. Plan ahead and get as much ready as possible
3. Position your mask and glasses or eye shields
4. Wash hands again
5. Put on gloves
6. Keep contact of instruments, supplies, equipment to minimum
7. If you need to retrieve additional supplies have a second retrieval instrument available
8. Make use of a second assistant to place and remove lead aprons for x-rays, remove bibs, fetch additional supplies, take notes, dismiss patients, etc.
9. Use gloves on both hands when cleaning up and reassembling instruments and for carting to sterilization area and discarding trash.
10. Separate trash into sharps, highly versus minimally contaminated
11. Wash hands
12. Put away clean items
13. Place a glove on one hand only for disinfection. The gloved hand holds the paper towel or cloth with the chemical disinfectant. The ungloved still clean hand contacts poles, door knobs, drawers, hoses, etc. In this way we avoid spreading more contamination than we are removing. The ungloved hand holds the spray bottle.
14. Be generous with disinfectant and purposely focus on what was actually contaminated. Be generous with amount, concentration and time spent.  
15. Remove the one glove and wash hands again.
16. One more tip – in the sterilizing room do not wear gloves for any other reason than touching contaminated not yet sterilized instruments.
     
    True this is not a sterile world. None of us no matter how hard we try are perfect. If we are going to promote the most good and do the least harm, we need to have sensible methods. We need to be much more similar and not so diverse when it comes to extremely important habits.
     
    I will end with a quiz I often give to employees:
    1] Would you remove your gloves and immediately eat your lunch without washing your hands?
    2] Is there really a “5 second rule”

Who decides your dental care?

How do you decide whether to seek dental treatment? Are you usually preventive minded and proactive? Do you only call when you sense discomfort or an obvious cavity, fracture or serious gum problem?


When you do decide to schedule with a dental office are you referred by a friend or family member or do you search the internet or telephone book or other direct ads? Do you consider any dental practice or are you strongly motivated to go where your dental insurance is in network for PPO discounts versus normal acceptance of your plan?


Do you believe there may be any difference in the quality of treatment you receive based on cost?
Is the treatment that you need so routine that you feel it makes little difference.


If you do need major procedures such as a root canal or bridge or some treatment of your front teeth would that make a difference? Do you believe that all dentists have similar experience and spend the same amount of time or use the same quality labs and supplies?


For some patients the answers to some or many of these questions is: "It does not matter at all or very much". They will then be highly persuaded to go with the "cheaper and faster the better" formula.


Many other patients do realize there is a difference.


It is true that new dental graduates will have very similar training. After that point there will be a very wide range. Doctors have choices to make regarding what equipment and supplies they purchase. They can very greatly with respect to the additional training they receive and use after dental school. They also have the ability to choose how much time they want to spend on patients and relate their focus and time to the fees they charge. The Dentist and staff spend time diagnosing your health status and then educating you. They not only perform your actual treatment but also strive to make you comfortable during that treatment and when providing you with temporaries and post op care. In addition to the amount of focus and time spent , there can be  much variation regarding quality of lab work and materials used for your treatment.


We believe patients have the right and responsibility to choose. It is a good thing to have dental insurance. It should be seen as a helpful benefit whether it pays in full or just a portion.
Unfortunately too many patients are strongly swayed by things that are not under their direct control. Your employer or union often decides which insurance plans to offer. Your insurance plan decides which procedures to cover and to what extent. The fee schedule designed by your particular plan may be anything from very basic to generous. It is really up to you, the patient to decide what you are comfortable with.


In the last 5 to 10 years there has been a great amount of change within dental insurance. As we all know, there have been major changes due to the Affordable Care Act (Obama Care). Thus fare the effect on dental and eye care has been minimal and indirect compared to medical coverage and for some the ability to sustain a full time employment.


I believe that our influence by politicians and insurance companies has already had significant effects on dental as well as medical care. While the goal was to spread health care to those less fortunate, there has unfortunately been adverse effects on those who previously had coverage and access to care. Many of us realize that there are ranges and different standards.


I will address this more in my next blog.

Post treatment guide for dental implants

**These are GENERALIZED instructions for your information only; they are not to be used for self-diagnosis or self-treatment. Please see your personal dentist for your own care.**

Post Treatment Instructions 

First 24 Hours

Completely avoid eating and brushing and touching area

Use cold pack gently outside skin for first 1 – 2 hours on and off 10 minutes

 

Usually all bleeding has subsided by time you are dismissed. There is some possibility of the return of bleeding later as the local anesthetic wears off and the Adrenaline effect on the blood vessels ends. It is normal for your mouth to have the taste of blood and for a very small amount of clotted blood to mix with your saliva. However, if you actually develop bleeding do the following:

Place a cold pack back on the outside of your face in the area and place  a wet tea bag insiden the mouth directly over the site and gently bite to allow the tea to coagulate the blood

Unlike usual extractions – DO NOT BITE ON GAUZE – pressure may disturb implant, bone graft healing process

 

Days 2 – 14  Continue to avoid eating and brushing in surgical area completely

Restrict all eating to the opposite side of the mouth. Chew carefully

The most important requirement is to avoid disturbing the area while healing is proceeding.

If a tooth was extracted, bone grafting, implant placed either separate or in combination; any force will cause shifting and will disrupt closure of the surgical site, movement of bone graft materials or membranes. Implants must be integrated within the bone for a minimum of 90 days for routine conditions before being subjected to force from chewing.

In lieu of contact even with a soft tooth brush applied gently, we recommend:

Rinse 3 – 7 times daily with  baking soda (one teaspoon dissolved in 8oz water)

There is also available a mouthwash with baking soda as the main ingredient. ( Tom's )

 

Use of temporary bridges, retainers, dentures - It is extremely important to prevent any direct forces on healing tooth sockets, bone grafts and healing implants.

 Special Instructions

Day 15 – 1 Month   sutures have been removed and the doctor has verified initial healing:

For two additional weeks after suture removal do brush the teeth adjacent to the extraction, bone graft, implant still being very gentle - only clean the teeth - do not massage the gum tissue that was involved in the surgery. Floss gently any adjacent teeth but do not force floss into crevice of gums immediately in the area of any implant or bone graft

Continue eating carefully still avoiding even soft foods on the surgical area.

 Any temporary restoration worn during the healing period should exert zero force on the area surrounding the implant and any bone grafted area.

 

Month 1  through [   ] 4    [   ]  6   [   ]  8

dependant on how many phases from toothy extraction through the time implant is determined to be fully integrated (secure in the bone)

During this time there are two very important requirements to adhere to

1) Forces upon the healing graft or implant must be avoided entirely

2) Cleanliness is imperative throughout the remaining period for healing - and forever thereafter!

 

Since there is a wide range of situations, I will describe all of them and note which ones pertain to your individual circumstances

 

Stage one - No exposed Implant structure and no temporary appliance

Avoid eating moderate to crunchy and sharp foods in the area

Brush and floss adjacent teeth like normal

 

Healing Abutment exposed to the surface

Avoid anything but extremely soft from contacting the exposed Titanium part

In addition to normal care for the neighboring teeth keep the abutment and surrounding gum tissue clean by gentle brushing in a circular motion

 

Healing Abutment with a Removable temporary appliance

Use the same above precautions to avoid forces upon the exposed metal part and to keep it clean.

Eat with the temporary appliance in place according to your previous instructions based on the durability and stability of your particular temporary. Clean the removable appliance at least three times daily - as soon as possible after each meal. If you detect any movement where the appliance transmits force to the abutment or the gum tissue around it call the office and avoid further use until adjusted

 

Multiple Implants with a Temporary Full or Partial Denture  

Avoid use of denture adhesive while stitches are in place and until gum tissue has healed closed - usually 2 - 4 weeks after extraction or implant placement.

Keep denture clean outside and under brushing soon after every meal

There should be no force upon the healing sites - any force from chewing must be on the palate and remaining teeth and ridge areas that are well healed where teeth have been missing for more than a year.

Eat only soft foods the first 30 days and only gradually to moderate chewing until your implants are integrated and a permanent denture or bridge is placed       

 

 

crown or bridge attached to implant(s)

You were supplied with a temporary attached to the implant for the purpose of shaping the surrounding gum tissue in the final stages of healing.

 In some cases (this is to be avoided since it is a compromised situation with much higher risk) a temporary may be attached to the implant immediately or much sooner than the time of full integration due to the impossibility of fitting a suitable removable temporary and a strong need for cosmetic appearance during healing.

[   ] Phase one - completely avoid all eating that would contact the temporary tooth and transmit forces - Extremely Important - not even soft contact. Do not brush the temporary but instead rinse 3 - 7 times daily with baking soda solution

 

[   ] Phase two - still continue to completely avoid eating on the temporary.

Brush with most gentle brush and method Do Not Floss the area

 

[   ] Phase three - Now we are in transition toward the final replacement tooth crown or bridge. Start eating very soft foods on the temporary. Brush with normal massage of the gum tissue like you would for any other teeth. Begin flossing around the temporary very gently with light force only against the temporary and no force from the floss exerted against the gum tissue

 

Special Instructions

You have been recommended to wear an appliance at night - either your temporary denture, a second denture or a night guard retainer. This is extremely important since we need to remove all risk of forces on the healing site, any implants with healing in progress, any implants that will stand alone (when usual day time denture is removed) even after they have fully integrated within the bone (we need to assure that they will not loosen, break screws, etc.) We also need to avoid unbalanced forces on any remaining teeth or trauma to your lips or tongue, etc. caused by clenching teeth during sleep especially when there are few remaining teeth that would be very vulnerable to problems.

In addition to protection, this allows the opportunity for soaking of removable dentures or retainers for maximum disinfection when they are out of your mouth.

Other:

 

 

 

After PERMANENT restoration

Gradually increase chewing reaching normal frequency and texture of foods.

Always avoid  extremely hard chewing such as ice, hard candy, shells, stale nuts

and  using your teeth as a tool or for bad habits.

Keep in mind that anything too strong will cause damage to natural tooth enamel, porcelain and other restorative materials, dental cements (even permanent) and can result in broken screws, loosening of crowns, bridges, posts, implants or teeth themselves.

Brush normally and often Floss gently around any Crown, etc. placed on top of the implant . Do not force floss deep under the gums around the body of the implant   gums do not attach as firmly to an implant as a tooth root  Gum and bone grow closely around an implant, but do not biologically connect

Implants will not be subject to cavities, but they are highly vulnerable to gingivitis.

Eat well without overloading  Use excellent cleaning at home and be consistent with follow up care every 3 - 6 months as recommended

 

 

 

                       Summary - Instructions for Dental implants

 

1) Day before / day of surgical placement

 

Take anti-inflammatory pain medication 1 - 12 hours in advance to prevent excess swelling and pain

Take antibiotic starting day before to prevent infection

 

 

2)After surgery through two weeks - removal of stitches

 

Completely avoid eating in area

Completely avoid brushing and flossing in area

Instead rinse gently and frequently ( 5 - 10 times a day) with baking soda solution or baking soda mouth wash only

Completely avoid use of any removable false teeth, temporary, retainer, night guard unless you were specifically instructed to do so and given special instructions for wearing and cleaning, removal

 

3) Following removal of stitches

 

brush adjacent teeth gently but thoroughly

rinse briskly with any type of mouthwash at least 3 times daily in area of implants

still do not floss the gum tissue next to any implant

If a screw or healing abutment is exposed now or becomes exposed in later weeks, begin gently brushing the exposed metal with a circular motion.

 

 

 

Under no circumstance should any force be placed from chewing upon an implant prior to a minimum 3 month period for integration (healing within your jaw bone)

 

exceptions are specially given when a patient has received a full arch set of implants that are joined by a rigid bar and a special secure temporary - still use great caution to chew very softly for the initial 3 month period

 

4) After restoration of implants

 

once any single crown, bridge or removable restoration is attached to the implant:

 

Chew softly at first then gradually increase until normal (mildly crunchy) can be accomplished - usually over a period of a week.

brush the fixed restorations the same as any natural tooth covered with a crown, bridge

Do floss the gum tissue over the implant - extremely gently - wipe gently against the implant and crown - do not use any force pushing against the gums surrounding any implant now or ever in the future

 

removable partials and full dentures are removed for cleaning three times daily and the implants should be brushed with a gentle circular motion.

**These are GENERALIZED instructions for your information only; it is not to be used for self-diagnosis or self-treatment. Please see your personal dentist for your own care.**

Broken crown or temporary? Read before you DIY

Dr. Raymond E. LaVigne practices dentistry in Palatine, Illinois.  His specialties are cosmetic dentistry, dental implants, and patient education. The focus of this article will be to help patients avoid the problems associated with delay in seeking professional care with or without an attempt to repair or glue teeth themselves at home.

F.Y.I. why D.I.Y. may not always be I.Y.B.I. ( in your best interest)

Life has its surprises. In addition to all the possible mishaps with our homes, cars, plans and the weather to mention a few; our teeth will sometimes add to our daily challenges.

Typical scenarios are a broken or lost filling, loose or lost crown or bridge or perhaps some type of breakage with a full or partial denture. Less common is a sudden problem to natural tooth enamel.

The most common reasons for these problems are:

• An extra hard shock to our tooth or restoration while eating
• Eating something of more than recommended hardness or stickiness
• Using our teeth as tools
• Clenching and tooth grinding due to stress
• Dropping our mouth appliance on the floor or sink
• Traumatic injury – falling down, running into something or somebody

The above factors can cause a good tooth or strong restoration to break or become loose.

When a tooth has already been weakened by decay or has a filling or crown that is not in good condition, even mild forces can cause damage.

Another possibility is when we are undergoing treatment and have a temporary filling or crown or bridge, denture, etc. Brushing too vigorously or chewing even the softest foods can break or dislodge temporaries. Dislodging temporaries while flossing is also a possibility.

(images of broken crowns and temporaries)

 

The problems we see or hear about most commonly are:

1) The crown or bridge does not get reinserted correctly – bite is off; restoration is raised so that repeat loosening is a probability and worse yet, decay or serious staining can get under the crown.

2) The tooth does not get cleaned and dried without having access to dental instruments and equipment and professional experience.

3) The excess glue cannot be adequately cleaned off or the crown is bumped loose in the attempt.

4) The patient secures the crown or bridge but does not follow up with the dentist. In the future significant decay is found.

5) The glue sticks to the patient’s fingers, lips, tongue or opposing teeth.

6) The restoration falls into a sink or is swallowed.

Here are some examples of products used by patients at home (real life stories from my office!) They  are absolutely not recommended to be used in the mouth or to repair any appliance that is placed in the mouth.

Temporary cements available in pharmacies or even at your dental office may be free of toxic substances in household or commercial adhesives, but still need to be used with caution as I will explain in a minute.

Below are the various cements and tools used by dentists for temporary and final cementation. In an office such as ours, we typically have 6 – 10 types over a wide range of strength. The photo in the middle shows a typical set up in a dental office for cementing or recementing. Dentists have cleansers for both the tooth and the crown. They also have water spray, suction and cotton rolls at their disposal. Their instruments include spatulas for proper mixing and loading, mirrors for looking into as well as guarding the tongue or cheek once the tooth is cleaned and dried.

Various dental products are used to decontaminate the crown and the tooth. Chemical agents are also used for preventing bleeding from the gums.
 
Also, before mixing the new cement, the old cement must be cleaned out.

The direction that the crown faces must be known.
When in doubt try laying the tooth down in various directions to determine the correct orientation.

Thank you for reading,
Dr. Ray

Dr. Raymond E. LaVigne DDS is a practicing dentist in the Chicagoland area for over 30 years.
Please call our Palatine, IL dental office for an appointment: 847-359-1292.