First Article (issued September 2003)

This is my first article for our new web page. I have decided to use it to briefly outline the format for upcoming articles which I will present. The purpose of these articles is to inform you about the wonderful world of dentistry whether we'll be discussing toothpaste or different treatment options. It is to empower you so you can make the best choices for yourself. These articles will be produced bi-monthly and either one of the dentalcare team or myself will be involved in the creation. Sometimes we will keep the content simple and sometimes we will be very technical. In any case, you'll find them highly informative and easy to read.

More importantly, these articles will stimulate your curiosity and hopefully your questions will be answered. We will encourage your e-mail, faxes or snail mail. And we will try to answer promptly!

So until we've ... read. . . again.

Sincerely yours,

M.J. Racich

Prevention (issued January 2004)

Dentistry has made many strides over the last century and has become a highly
predictable health care profession. What only a few years ago could cause mortality (e.g. an abscessed tooth) is now routinely and quickly treated. We owe this incredible ability in part to the tremendous research and product development that has occurred, but also the dedication of numerous dental professionals.

One of the first concepts that are put forward to dental health care students is prevention. The major dental diseases are preventable today. Tooth decay, gum disease and toothaches to name a few, we can control and eliminate with currently accepted oral health practices such as hygiene and fine dental restorations. Furthermore, we are also able to improve oral function and comfort with many existing and new, exciting techniques that today's rapidly changing technology provides us. Contact our office at your convenience so that we may discuss these with you.

It is important for the public to be aware of this and to be willing participants in improved health. Going regularly for dental examinations and preventative maintenance treatment such as hygiene visits can do this. As well, it is equally important to develop a long-term and trusting relationship with on oral health team that can monitor your progress. At our office, we pride ourselves in being able to help people optimize their oral health. We listen to our patients wants and try to fulfill their dental needs to the best of our abilities.

I hope the New Year is healthy and prosperous for all.

Happy New Year,

Sincerely yours,

M.J. Racich

Total Care (issued March 2004)

Our TEAM is proud of our ability to provide comprehensive dental care that incorporates the total person. From the initial contact that a prospective patient has with our TEAM to the ongoing interaction that evolves over the years we look and care for the wants and needs of the total person.

We do this by not only staying current on all the latest dental materials, techniques and technology but also taking numerous courses on auxiliary and alternative therapies. For example, in early March Dr. Racich attended a two day cranio-sacral orthopedic course that involved not only instruction but also hands on training. Furthermore, our practice is involved with and is a member of the Vancouver Pain Network whereby we interact with numerous complimentary health care professionals for our patient's pain concerns and also their nutritional, emotional and physiological needs. We enjoy the challenges that total care brings and look forward to helping those people who are so kind to come to our practice and interact with us.

We invite you to contact us and explore our concept of total care to facilitate optimal oral health for yourself. You truly can have the appearance, function and comfort that you deserve for a lifetime. Our TEAM welcomes you.

The Team

To Whiten or Not To Whiten - Here are Your Options (issued October 2004)

In this day and age, it is almost impossible to find a product in the drugstore that does not promote whitening. From toothpaste and floss to even chewing gum, whitening and brightening is this decade cosmetic focus.
There are many products that promise a "movie star" smile, below are some of the options available to the consumer. Always consult your Dental Professional if there are any questions or recommendations required.

POWER BLEACHING/LASER WHITENING
Whitening power intense

Hydrogen peroxide-based gel is applied to teeth, and then directed with high intensity light. The light activates the gel, allowing it to penetrate the tooth's surface. This procedure is performed in a dental office.

CUSTOM-MADE WHITENING TRAYS
Whitening power intense

The dental office makes a custom guard or set of trays formed to the exact shape of your teeth. The whitening gel is a thick solution that is dispensed into the form-fitting tray and worn overnight/ during the day for approx. two weeks.
The active ingredient in the gel (carbamide peroxide) is broken down, oxygen enters the enamel and dentin and bleaches the discoloured surface. The structure of the tooth is not changed, only the tooth colour becomes lighter.

OVER THE COUNTER WHITENING TRAYS
Whitening power moderate

How they work- for this technique you purchase trays and product at a drug store, rather than having trays custom made. After biting into the trays to create an impression of your teeth, you fill the trays with the whitening agent and wear them each night for an average of two weeks.

WHITENING STRIPS
Whitening power moderate

Clear, thin strips coated with a peroxide-based gel are affixed to teeth for 30 minutes twice a day over a period of one to three weeks, depending on the brand and formula

BRUSH ON BLEACH
Whitening power mild to moderate

This process involves bushing a peroxide-based gel directly onto teeth to be worn overnight

TOOTHPASTE WITH PEROXIDE
Whitening power mild to moderate

A weak concentration of peroxide works to fade surface stains

Jennifer Bartolotti, Hygienist

Has there been something that has prevented you from smiling over the years? (issued April 2005)

If it's a gummy smile, today there are many solutions. You may be surprised to hear that your smile could be improved without any major surgery. Let' get you smiling again, whether too much of your gums show, your teeth look too short, or your teeth look like they're all different lengths. Confidence can come through a smile, so don't let anything stop you from doing so.

Everybody is different, therefore every gummy smile needs a special approach. Sometimes carefully recontouring of your gums will be all that is needed. Special tools are used to carefully check your bone and gum line. Immediate results can be also seen by having something called aesthetic crown lengthening. Your dental team could also suggest a combination of whitening treatments, changing of your silver restorations to tooth coloured restorations and then eventually replacing them with porcelain for strength and durability. Visit your dental team to get a clear understanding of what they can do for you.

In the year 2005, materials are getting stronger and dentists are getting more educated with better techniques therefore enabling them to achieve amazing results. Nothing should prevent anyone from smiling. Almost anything is possible. All you have to do is ask…………….

May Javiniar , certified dental assistant

ARE YOU BRUXING YOUR TEETH? (issued October 2005)

Bruxism: the technical term for clenching and grinding your teeth that is something that up to 33% of the population does. Some people have difficulties dealing with stress or have nervous tension and unknowingly take out their frustrations through their teeth and jaws. Sometimes sleeping partners can actually hear the grinding noises produced when the bruxer is grinding. Science is also revealing that bruxism can be related to sleep disorders such as obstructive sleep apnea. Often young children will brux their teeth, but that is usually a passing phase in development.

Your dentist can see signs of bruxism with an examination of the teeth and oral mucosa. The teeth cusps (points) flatten out and can sometimes expose the dentin, there can be hairline cracks in the teeth, and the tongue may show crenulations or indentations. The dentist can also listen to your temporomandibular joints (TMJ's) for clicking or popping noises. Patients may notice upon awakening tightness in their jaw muscles and teeth can become sensitive to pressure and temperature. Also, it is thought by some that gum recession can be promoted by bruxism. Bruxers may also have other oral habits such as chewing fingernails and pencils, or chewing the inside of their cheeks.

WHAT CAN BE DONE?

Your dentist can recommend treatment such as an orthotic (night guard) that will not necessarily stop you from bruxing but it will act as a buffer to help protect your teeth from wear. Further investigations such as sleep studies are often indicated as well. There are hard and soft orthotics that are fabricated from acrylic materials that are fitted over one of the arches of teeth. Also having the awareness that you are bruxing can help you stop bruxing (when aware your teeth are touching put your tongue on the roof or your mouth and you will automatically stop touching). Using self-help techniques to aid the patient in reducing stress levels, or dealing with anxiety and stress in other ways such as exercise, not overextending yourself with work or family commitments, etc. Biofeedback is another option being used for diurnal (daytime) grinders by the use of electronic instruments monitoring the muscle movements and to teach patients to reduce their muscle activity when biting forces become too great.

WHAT ARE THE SIGNS OF BRUXISM?

1. teeth look flat (cusps worn down)
2. fractured teeth or dental restorations
3. tooth sensitivity (dentin could be exposed)
4. gum recession (a possible outcome)
5. tight jaw muscles
6. tongue crenulations (indentations)
7. noises and /or pain of the TMJ's

Please contact your dentist if you know or think you are clenching or grinding your teeth, you may be a bruxer.

Camille Hankey, office coordinator

Fluoride, a natural contribution to your dental health (issued October 2006)

Did you know that fluoride contributes to your oral health and helps to fight tooth decay? Find out how to use fluoride wisely.

Fighting tooth decay, naturally

Fluoride occurs naturally in rocks and soil and is among the most abundant substances in the earth's crust. As a result, it's often found in a dissolved form in lakes, rivers and groundwater. Because fluoride is so common, and because human activities such as manufacturing release it into the air, all vegetation and almost all foods contain traces of it.
As early as the 1930s, scientists noticed that people who drank naturally fluoridated water had less tooth decay than people who didn't. They soon realized that fluoride might be nature's answer to tooth decay, and more research in the 1940s and 1950s showed that it could contribute greatly to dental health.
As a result, many communities in Canada and the United States began to add fluoride to their drinking water. Manufacturers of dental care products also started putting it into toothpastes, rinses, gels and varnishes. Dietary supplements like fluoride lozenges also became available. With these products, fluoride is available to everyone, even when their water doesn't contain it.

How fluoride works

Tooth decay results from the effects of acids on the minerals in your tooth enamel. These acids are produced by bacteria in the mouth and literally dissolve the minerals right out of your teeth.
Not only does fluoride protect your teeth from the damage caused by acids, but it also stops bacteria from producing the harmful acids in the first place. In addition, it helps your body replace the minerals in your teeth, repairing the damage the acids have done. And with children, the right amount of fluoride helps their enamel mature.

But is it good for me and my family?

Many scientific studies over several decades show that water fluoridation is good for oral health. As a result, Health Canada recognizes fluoride as a beneficial substance that helps prevent tooth decay.
The Canadian Dental Hygienists Association (CDHA) also considers fluoride use to be important for oral health and disease prevention. The CDHA recommends that everyone should brush with a fluoride-containing toothpaste at least twice each day.

Using fluoride wisely

While fluoride is generally good for oral health, too much can cause a problem called dental fluorosis.
This happens when too much fluoride affects tooth development by interfering with the mineralization of the enamel. Mild fluorosis affects the enamel's outer layer, producing white lines across its surface. With severe fluorosis, the enamel becomes porous, which can result in tooth sensitivity or pain. This, in turn, can lead to other problems. Because of this, the Canadian Dental Hygienists Association discourages the overuse of fluorides by children and recommends the following:

o Infants past the age of 12 months shouldn't be fed with formula made with fluoridated water.

o Children under six can get unneeded fluoride through accidental swallowing of toothpaste, so parents should supervise them to make sure they put only a thin smear of toothpaste on the brush.

o Before children receive fluoride supplements such as lozenges, their parents should consult with a dental hygienist to obtain an individualized assessment of tooth decay, oral health and exposure to all sources of fluoride.

o Children over six, if they're at high risk for tooth decay, may require a supplement of 1 mg/day, but only if the water supply is not fluoridated, or is fluoridated at less than 0.3 parts per million (ppm). Again, no supplements should be given until the parents have consulted a dental hygienist.

o Before children receive fluoride supplements such as lozenges, their parents should consult with a dental hygienist to obtain an individualized assessment of tooth decay, oral health and exposure to all sources of fluoride.

Fluoride Use For Adults

Adults also require fluoride in order to maintain and prevent dental decay. It is often thought that only children require it's benefits but as we age our need for it's preventative properties become even greater.
Many older adults who take multiple medications find that a common side affect is a "dry mouth". These individuals are at a higher risk of "root surface decay" due to their limited saliva production. Saliva is a naturally occurring buffering/cleansing agent. Without sufficient supply the "softer" root surfaces are not protected and are easily attacked.
Your dental hygienist may recommended a Home Fluoride Rinse or Gel to help control the acid levels in your mouth.

Jennifer Bartolotti, Hygienist

Keeping It Clean (issued March 2007)

The Vancouver water "problem" of 2006 brought a lot of chickens home to roost. We are sure most Vancouverites were not only shocked but also disappointed with the state of affairs with regards to our potable water supply. We know that we sure were, but we were not totally surprised. The logging near our watersheds a few years back did not make sense then and the wisdom of such a move definitely makes us wonder what the preparedness and safety level of other essential services are as well.

The issue of a clean, sanitary water supply was addressed in our office years ago. We have bypassed the local water system for years and have provided our patients with an independent source of water for their treatment. Specifically, we use distilled water that is supplied to a reservoir attached to the side of the dental chair that is replenished daily. The following picture shows one our set-ups.

We pride ourselves in keeping a clean, sanitary, ergonomic office. State of the art sterilizers are used which are regularly spore tested to verify proper, optimal function. All materials that are used in the mouth and about the face area are either sterilized or discarded. High level disinfection of all the treatment rooms is performed after each client leaves regardless of the complexity of the treatment. Our patient's health, safety and comfort are foremost on our minds every day and every hour that we spend in our office.

Next time you visit our office please feel free to ask one of us about our sterilization and disinfection procedures. As you already know, we like to empower our patients with knowledge.

M.J. Racich

I already brushed my teeth... I'll just have some raisins instead... (October 2007)

And so Alice ended up in her dentist's chair, asking: "Why do I keep getting all these cavities?". Alice, like countless others, was unaware that natural sugars are on equal footing with refined sugars when it comes to cavities.

Cavities are the result of enamel breakdown caused by the formation of bacterial byproducts (acids). Caries is the disease; cavities are the results. In order for a cavity to form, three components are necessary: a susceptible host (the tooth), bacteria (the pathogen) and fermentable carbohydrates (the supply). Take away a part of the equation and the chain is broken. Since we cannot eliminate bacteria from the oral cavity the factors we can control are the teeth and our fermentable carbohydrate consumption.

Any food that is broken down into simple sugars has a cariogenic effect, be it the concentrated sugars in dried apricots or the sugars in milk products. That being said, not all foods are created equal. The factors that become important when making food choices are: the types of food we eat, how often we consume these foods, and what we eat with them. Often, when we eat, we create an acidic environment in our mouths. Reduce the frequency of food consumption and we thus reduce the number of times our mouth becomes an acidic environment. In addition, when fermentable carbohydrates are eaten as part of a larger meal the other foods eaten will have a buffering effect and help reduce tooth breakdown. Therefore, it is better to consume fermentable carbohydrates with other foods, not as snacks. For example, a piece of white bread is better consumed with natural peanut butter than with honey or alone. The white bread will be broken down into simple sugars as will the honey. The natural peanut butter will create a buffer and help to reduce the cariogenic effect of the white bread.

Another good way to reduce our risk of developing cavities is by keeping our teeth strong and healthy. Fluoride is a great way to ensure this. Fluoride strengths the enamel matrix and makes it more resistant to breakdown. Choose toothpaste that contains fluoride and use it at least twice a day. Also, most municipalities have a fluoridated water supply. If you are unsure whether your community is fluoridated phone the local public health division and inquire, they will be able to provide you will all the necessary answers. In addition to the fluoride received at the dental office there are also a variety of rinses and gels for at home use for individuals with a history of caries.

The best way to ensure we are not creating acidic environments in our mouths is to reduce our fermentable carbohydrate consumption and to eat them with meals. It is also important to remember that caries is a communicable disease and can be transferred from one person to another. With that in mind don't share toothbrushes or any device used intra-orally. Choose fluoridated products for at home use and, with that, savour the ice cream eaten after dinner.

Fiona Simmins

Evidence-based Dental Health Care (July 2008)

Evidence-based health care is the "...conscientious, explicit, and judicious use of the current best evidence in making decisions about the care of individual patients ... including integrating individual clinical expertise with the best available external clinical evidence" as described by Dr. D.L. Sackett. The medical profession has been teaching this model of care over the last two decades and more recently denistry has followed suit. Simply stated, the health care provider needs to not only keep up-to-date with techniques and materials but also has to utilize proven techniques and methodology. Personal biases notwithstanding, the health care provider then needs to inform the patient of what his or her options are. Based on the evidence, prudent decisions can be made.

A good example of evidence-based care is the selection of medications. Depending on the medication, numerous studies can usually be found related to clinical trials. High quality studies are sought; they are placebo controlled, randomized, and blinded (unlabelled). Neither the therapist nor volunteer know which medication is being utilized. Therefore, utilizing the information from studies such as these, both the practitioner and the patient can choose a medication with proven efficacy on high level, non-biased evidence.

Evidence-base health care has become easier to practice thanks to the internet and such fabulous search engines as Google. All one has to do is log onto Google, type in the subject, being as specific as possible, and select the websites of interest. Medline searches will usually appear. One needs not to be afraid of the scientific articles that appear on the Medline search since they all contain an abstract at the beginning of the article. Abstracts are short summaries of the paper and usually they have one sentence conclusions of the results. Many dental articles also have a clinical significance section. Moreover, there is a website that contains systematic review articles (highest level of "evidence") not only on dentistry but also other health fields. This site is the Cochrane Systematic Review Collaboration; just log onto the site (via Google, for example). The "history" of the Collaboration is well documented in this website. The reviews of the various health areas are in the "library" section. Just find your topic of interest and read the summary of the best evidence as reviewed by a panel of experts.

In pratice we follow the evidence-base model of care. We would be pleased to discuss this with you further at your next visit to our office.

M.J. Racich

Bad Breath: It Doesn't Have To Be So (December 2008)

Halitosis, or bad breath, affects countless numbers of people worldwide. In most cases, people with bad breath aren't even aware of the problem. Halitosis has a significant impact, both personally and socially, on those who suffer from it. If you think that you suffer from bad breath, our dental team can help determine the source of the odour. If our dental team believes that the problem is caused from a systemic (internal) source, such as infection, we may refer you to your family physician or a specialist to help treat the cause of the problem.

What causes bad breath?

Typically, bad breath originates in your gums and tongue. It is caused by waste from bacteria in the mouth (especially from those with periodontal disease), decayed food particles, other debris in your mouth, and bad oral hygiene. The decay and debris produce a chemical compound that causes the unpleasant odour. Bad breath may occur in people who have a medical infection, diabetes, kidney failure, or liver malfunction. Even stress, dieting, snoring, age, and hormonal changes can have an effect on your breath. Xerostomia (dry mouth) and tobacco also contribute to the problem.

What is morning breath?

Saliva is the key ingredient in your mouth that helps keep odour under control because it helps wash away odour causing food particles and bacteria. When your sleep, however, salivary glands slow the production of saliva, allowing bacteria to grow inside the mouth, which causes the bad odour, or "morning breath". To alleviate morning breath, brush your teeth and eat a morning meal. Morning breath also is associated with hunger or fasting. If you skip breakfast, the odour may reoccur even if you've brushed your teeth.

Do certain foods or drinks cause bad breath?

Very spicy foods, such as onions and garlic, and drinks like coffee may be detected on a person's breath for up to 3 days after digestion. In addition, certain diets, especially ones that eliminate carbohydrates, increase the chance of halitosis.

How can I control bad breath?

Visit our dental team regularly because checkups will help detect any systemic causes. Checkups can also help get rid of plaque and bacteria that build up on your teeth.
It is important to practice good oral hygiene, including brushing and flossing your teeth at least twice a day to remove bacteria, plaque, and food particles. To further eliminate odours, clean your tongue with your toothbrush or a tongue scraper (a plastic device that scrapes away bacteria that builds on the tongue).

In addition, be sure to drink plenty of water. Try chewing sugar-free gum that contains xylitol which tends to increase salivary flow. If you have dentures or a removable appliance, such as a retainer or mouthguard, clean the appliance thoroughly before placing it back in your mouth. Before you use mouthrinses or deodorizing sprays or tablets, please consult with us, because some of these products do little to negate bad breath. Instead, your dental team can recommend products that have proven successful.

We look forward to your next visit to our office when we can discuss this topic or other topics of importance to you so that we can help you optimize your oral health.

M.J. Racich

Triad Algorithm
Reference: Team Work 2009;2:8-9. (posted here in May 2009)

Sitting under a tree one hot summer day last year, sipping a cool one, and contemplating how I was going to continue saving the Nations teeth over the next few months, it occurred to me that how I practice dentistry can be summed up in the following algorithm (which I just so happen to call Racich's Triad Algorithm).

Racich's Triad:
1. Evidence-based dentistry (EBD)
2. ABC's
3. 1,2,3's

stop = review, reconsider, re-relate, release, or retrain

Let me now explain. In order to practice contemporary dentistry, the dental team first and foremost needs to follow the principles of evidence-based dentistry. We discussed evidence-based dentistry in a previous issue of Team Work (CSI Dentistry) and as we discussed then, evidence-based dentistry involves the blending of the published evidence with patient beliefs and values as well as those of the dental team.1 All three of these variables must be favourable for evidence-based dentistry to be practiced. Looking at the algorithm we see that after the patient is introduced to our practice we explore the patient's beliefs, values, wants and needs; we decide whether they are compatible with our practice model; we explore the literature as needed to confirm the efficacy of any proposed treatment. As the algorithm shows, if any of these three evidence-based variables are not favourable then the dental team should stop, for to proceed would be pure folly. Stop means we need to either review what our motivations are, reconsider whether we want to proceed, re-relate or try to reconnect with our patient, release or terminate our relationship with our patient, or retrain in order to provide the care that has been requested. On the other hand, if the process of evidence-based dentistry has been successful with all three variables then the patient will give us their consent, an informed consent, to proceed. Without informed consent there is absolutely no justification to continue on with the patient-dental team relationship under any circumstances, period. Informed consent is the green light for the journey to begin.

Part two of the Triad is the A,B,C's.

A,B,C's:

A: Pre-treatment considerations such as evaluation of patient wants, needs, and expectations must be thoroughly explored. The ability of the dental team must also be realistically evaluated. Evidence-based dentistry considerations (Part one of the Triad) usually ensure that the "A" phase is looked after adequately.

B: The actual treatment phase (i.e. the 1, 2, 3's of Dentistry).

C: Post treatment considerations such as maintenance (dental team and patient's responsibilities) and warranty need to be thoroughly understood.

The A, B, C's involve pre ("A") and post ("C") care strategies while the actual treatment ("B") is the 1, 2, 3's.2,3 Interestingly, it becomes readily apparent that the actual physical treatment ("B"), i.e. what the patient thought they presented for, is in reality the last item to be dealt with using my Triad algorithm. Please also note that the management of the treatment provided over the years ("C") and the preparation for care ("A") are as equally important as the actual physical treatment ("B"). Once again, if we are not satisfied with the pre and post treatment considerations then it is incumbent upon us to stop (review, reconsider, re-relate, release, retrain).

"The way you see people is the way you treat them." Zig Ziglar

The last or third part of the Triad is what I like to call the 1,2,3's of Dentistry.4,5

The "1" is the starting point, the "2" is the anterior limits, and the "3" defines the finishing touches. I will explore the 1,2,3's of Dentistry further in future issues of Team Work but for now suffice it to say that even after the dental team has worked through evidence-based dentistry , the patient has provided their informed consent , and the dental team is secure with their pre and post treatment ("A & C") observations there is still one more opportunity to stop (review, reconsider, re-relate, release, retrain). For once we begin patient care we want it to proceed methodically and predictably (the 1,2,3's of Dentistry) to everyone's satisfaction. From the patient to the dental laboratory, all should be content.6 With successful treatment results comes increased team confidence and experience which then lends itself to improved evidence-based dentistry methodology. The cycle then repeats itself. The practice of dentistry then becomes more predictable and with increased predictability there is decreased stress, which is what we all want.

I believe that all aspects of patient evaluation and management can be satisfied by following my Triad algorithm. I hope you have enjoyed reading my brief thoughts on this topic as much as I have enjoyed sharing them with you. I look forward to spending time with you again soon. Always remember that you can contact me or any of the team at Team Work at your convenience.

References:

M.J. Racich