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18 Questions While You’re in the Dentist’s Chair

It’s National Dental Health Month. Really, you ought to appreciate it.

We've all been there. You're sitting on the dentist's chair, with your palms sweating. Maybe you're wincing, anticipating a needle full of Novocain or the high-pitched whine of the drill.

Maybe, like a lot of folks, going to the dentist makes you feel guilty, for not brushing or flossing or getting dental care as often as you should. Feeling guilty and anxious is never a pleasure. But before your negative feelings turn to malice, here are some answers to questions that may occur to you as you sit in the chair.

1. What if I just get off the chair now and never come back?

Other than losing all your teeth, there are medical complications that can occur if you do not get regular dental care. Left untreated, tooth infections can spread to the jaw and neck. This can not only be very painful, it can also block the airway. "I've seen people die from airway compromise in emergency rooms," remembers Dr. Bruce Todoki, an oral and maxillaryfacial surgeon, who takes calls at Kuakini and Queen's hospitals. "Sometimes I am called to take out bad teeth in patients who need chemotherapy, but, because they have not had dental care, the chemotherapy has to be delayed by a couple of weeks." Rarely, tooth infections can spread to the brain and cause bacterial meningitis.

2. Now that you have scared me, how does someone decide to become a dentist?

There are perhaps as many reasons as dentists, but most dentists say they knew they could solve real problems for people.

"I had really bad buck teeth in third grade, and my classmates used to make fun of me," remembers Dr. Joyce Hagin. "In fourth grade, I had braces to correct them, and I remember walking to school with my new, straight teeth, and I felt so happy. My mother also had bad periodontitis, and felt ashamed about her dentures. I felt bad for her. I wanted to go to dental school so that I could make a difference in people's lives."

3. What does it take to be a dentist?

Illustrations: Michael Austin

Perseverance and study. Dental school, like medical school, requires four years of graduate study after college. The first two years of dental school are spent mostly in lectures, reading pharmacology, physiology, biochemistry and, above all, anatomy of the tooth and surrounding structures.

During dental school, many hours are spent practicing drilling and filling on plastic mannequins. At the end of the second year, dental students practice giving injections to each other. The third and fourth years are spent in clinics. Unfortunately, in some dental schools, as in some medical schools, there is a form of official hazing. "We were made to feel stupid. The faculty did not treat us with respect, unless we had acquired some knowledge," remembers one dentist.

After dental school, most newly trained dentists start practicing as general dentists. Others train further for anywhere from two years to seven years, to become specialists. There is no dental school in Honolulu, but The Queen's Hospital has a dental residency program, where newly graduated dentists can spend a year further honing their skills in general dentistry.

4. Is a dentist the same thing as an oral surgeon?

No. In order to become an oral and maxillofacial surgeon, it used to take four more years of training after dental school, but now it takes seven years, including going through medical school. "I saw a lot of interesting cases when I trained in an Atlanta county hospital," remembers Dr. Lyle Yanagihara, a Honolulu oral surgeon. "There were a lot of gunshot wounds and serious infections that we just don't see here in Honolulu."

Compared to Atlanta, Honolulu is very quiet. Here we have mostly broken jaws and infections. How does one break the jaw? Apparently, there are quite a few fights here in Honolulu, that end up with broken jaws. Yanagihara explains, "if you hit another guy on the jaw at the right angle, it can break very easily." Sometimes, if there is an impacted wisdom tooth putting additional pressure, the jaw breaks even more easily. "Once I took care of a 60-year-old lady, who was playing tennis, fell on her chin and broke her jaw on both sides."

5. OK, I understand I need a surgeon if I get hit in the jaw. But what do I need a dentist for? Why aren't my teeth tougher? Shouldn't they be at least as tough as bone?

Like many people, teeth are only tough on the outside. The tooth itself has three main layers: (1) a very hard, outer core, usually called enamel, (2) a layer of bone tissue called dentin and (3) a soft pulp. The enamel is extremely hard, but also quite brittle. It is 97 percent mineral, made of calcium hydroxyapatite. It can withstand 100,000 pounds per square inch of pressure. The dentin is a bit softer, 70 percent mineral. The soft pulp is the sensitive part of the tooth, with many blood vessels and more than 2,000 nerve fibers per tooth. When the pulp gets infected, you get a throbbing toothache.

6. Why does the dentist stick that sharp dental probe all around my teeth? What are dentists "probing" anyway?

They are probing to make sure you don't lose your teeth. Try to think of it this way: Your tooth sits in a socket on the skull, like a flower in a vase. The upper teeth are attached to the maxillary bone, the lower teeth to the jaw bone. Each tooth is tethered by ligaments only 0.3 mm wide, surrounded and held in place by what we call gums and the dentists call gingiva. If the gum gets infected and goes untreated for too long, the socket melts away and your tooth can literally fall out.

7 . Even if I brush my teeth?

The pocket between the tooth and the gum is called the gingival pocket. You cannot reach it with your toothbrush. Therefore, it's a prime spot for what are called, if you'd gone to dental school, subgingival plaques. These plaques are coated with bacteria, and, if not cleaned by the dentist, will cause the gum to become inflamed, a condition called gingivitis. If gingivitis gets bad enough, it turns into periodontitis, which means you are losing gum tissue and even the jaw bone that supports the tooth.

8. How does the dentist's probe help?

The periodontal probe is used to measure the degree of gingivitis caused by bacteria. The deeper the probe can be pushed into the space between the gum and the tooth (it's called the gingival pocket, remember), the worse the inflammation. If the probe goes in quite deep, then the bacteria probably have done so much damage that part of the gum or even the bone has been lost.

9. How do I keep that from happening?

You start by brushing and flossing, of course. Your dentist can smooth out ill-fitting tooth fillings, and fill cavities. But a crucial part is to remove the plaque-well, really the calculi.

10. Calculus? Like math?

Calculi is Latin for stones (and the Romans counted with stones, which is where we get the words calculate and calculus.) But dentists call hardened plaques calculi. They are little stones on your teeth, and, since they are coated with millions of bacteria, unless they are removed, no matter how much you brush your teeth, the gums and teeth will continue to erode.

A dentist or a dental hygienist has to remove them.

11. Is that why the hygienist scrapes my teeth with what seems like an ice pick? She seems to be working awfully hard.

Some of the calculi are hidden between the tooth and the gum, so that you cannot see them or reach them with the toothbrush. The only way to get rid of them is to work very hard with that ice pick-like instrument, which, by the way, is technically called a curette.

When the hygienist uses the curette, she is trying to pull hard, so that the plaque tears out from the tooth. The plaque cannot be just scraped off. It must be yanked out. Your gums will thank her, even if you won't.

12. Most people don't get gum disease, right?

Wrong. According to Dr. Gregg Uyeda, a Honolulu periodontist (specialist in gum diseases), "More than 97 percent of people have gum inflammation or gingivitis." You need to know about it. "Education is most important," Uyeda adds. "It takes only five minutes, but every dentist should educate the patient about how important it is to control gingivitis." Through brushing and flossing and proper dental care, you can keep your gums in good shape.

13. Gums, gums, gums. Whatever happened to old-fashioned cavities?

People still get cavities. And you can loose your teeth two ways: from below through gingivitis and from above by acid generated by bacteria in the plaque. There are always bacteria in our mouths, but two cause most of the damage: streptococcus mutans and lactobacilli. These bacteria produce lactic acid, which not only causes inflammation of the gum, but can also melt away the enamel of your teeth to form cavities. Cavities can be prevented with tooth brushing, fluorides, diet, and fissure sealants.

14. What's the best way to brush my teeth?

"Just massage your gums gently with the toothbrush," advised Dr. Jun De Los Reyes of the Kalihi Palama Dental Clinic, "and always use a soft toothbrush. Don't try to dig into the gums, or the gap between the tooth and the gum.

15. What's a dental sealant?

Fissure sealants are like a clear plastic cover that the dentist can put over the teeth to prevent cavities. Since 90 percent of all cavities occur on the molars, where rough chewing surfaces sometimes cannot be reached by toothbrushes, and since fluorides do not protect well against molar cavities, dentists have been using sealants to prevent cavities in children. "Some Micronesian children, and many Asians, have very deep molar fissures," adds De Los Reyes, "and I use sealants quite often on them."

16. What about fluoride? Is it in the water?

No, our water is not fluoridated, except on the military bases. Fluoride occurs naturally in water, but at different concentrations in different parts of the country. In the 1940s, the U.S. Public Health Service found that there was a direct correlation between fluoride concentration in water and cavity rates. Fluoride was first added to tap water in 1945 in Grand Rapids, Mich. Now, 5 percent of all Americans drink fluoridated water. Fluoride in tap water has been shown to cut cavity rates in children by 50 percent and by 20 percent in adults.

"It is unfortunate that we do not have fluoridated water in Honolulu, because it helps teeth to become strong when the infants are still young," according to Dr. Nadine Salle, a pediatrician at The Queen's Medical Center. "Almost all pediatricians prescribe fluoride drops for babies starting at age 6 months."

The good news is that most toothpastes have fluoride now. Over-the-counter fluoride rinses are also available. In a study done in Norway, where 90 percent of children use fluoride toothpastes, using fluoride rinses decreased the rate of cavities by another 50 percent.

17. But fluoride won't keep me from seeing the dentist?

No, you need regular dental care to preserve your teeth. You don't want to have dentures, but you will if you don't control both cavities and gum disease. The best way to keep your teeth healthy is to have hidden plaques removed by a dental hygienist, to have cavities repaired by a dentist, by eating a healthy low sugar diet, using fluoride in either toothpaste or mouthwash and brushing your teeth and gums well at least once a day.

18. So I am happy to be in the dentist's chair?

Whether you know it or not, yes.

Glossary

Calculi: hard stones that form between the gum and the tooth, from plaques that are not cleaned properly.
Caries: tooth cavities
Enamel: the very hard, outer layer of the tooth
Gingiva: gum
Gingivitis: bacteria infection and inflammation of the gum
Periodontitis: bacterial infection of the gum leading to destruction of the gum and the jaw bone supporting the tooth
Plaque: invisible film of bacteria that coats the teeth and gums
Pulp: the soft, inner part of the tooth that’s very sensitive, because it is rich in nerves and blood vessels

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,February

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