Newark Dental Center

Dr. Gerald's Blog

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    Posted by Gerald Au on May 9, 2013
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    Gum Disease or Periodontitis

    The biggest threat to teeth are cavities and gum disease.

    When you come in to clean your teeth, we scrape off the hard deposits called tartar or calculus.  Calculus is covered with plaque and are full of bacteria.  The bacteria grow and irritate the gums.  The gums become red and start to bleed.  If the irritation persists then the bone around the teeth dissolves away.  If too much bone dissolves away, then the teeth become loose and fall out.  

    Gum disease is similar to hypertension.  By the time you feel it, it’s too late.  By the time you feel the teeth have become loose, there isn’t much we can do and the teeth will be lost.  Outward appearances may be deceptive.  The gums may be normal looking but the pockets underneath may be inflamed and deep.

    Teeth roots are covered with bone and gums.  Between the gums and teeth is a space called the pocket.  We measure the depth of the pocket with a probe and record the finding in millimeters.  3 mm is normal.  6 mm is gum surgery.  9 mm means the tooth is lost.



    The left side is normal, the pocket is shallow and the bone level is high.  On the right side is disease or the history of disease.  The pocket is deep and the bone level is lower.  



    This is a probe. The pocket is 5 mm deep and bleeds with touch. 



    This is the same patient. The dark lines at the gumline of the lower teeth are bands of calculus.  The gums are swollen, irregular in shape and bleed with touch.  Some bone has been lost permanently. This is moderate gum disease, Type 3. There are 4 types or stages of gum disease, 1 through 4, 4 being the worse.

    Because the patient is young, the prognosis is good.  The treatment plan prescribed is cleanings every 4 months.   

     
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    Posted by Melinda Lee on Apr. 29, 2013
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    This is a guest blog entry by Dr. Melinda Lee.

    Last month, I saw a patient for her recall appointment.  She is currently studying out-of-state so it was nice that she was able to coordinate her dental appointment with a family event.  It was a good time to catch up and understand how the economy is affecting our young people.  We ended the appointment with some long overdue pictures of her teeth.  She had some dental work done two years ago.  Can you tell which one is the veneer?  (Answer below.)



    I wish I had taken better pictures two years ago of the before situation.  But long story short, she had some congenitally small teeth, or peg laterals, in dental jargon. The orthodontist decided to arrange the teeth with ideal spacing to match the other side, and left it to me to veneer the front of the tooth to get a good esthetic match with the opposite side. I think it turned out very well.  So the tooth with the veneer is the fifth one in from the left.  FYI, the ninth tooth from the left is her canine, which is why it has a more angular look.  Maybe we’ll address that one in the future?



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    Posted by Gerald Au on Apr. 29, 2013
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    Dental Office Sterilization

    This year, an Oklahoma oral surgeon made headlines regarding infecting patients with hepatitis and HIV.  I closely examined the story on the ABC News website dated April 18, 2013.  I also was able to find the State complaint against the oral surgeon, posted by the State of Oklahoma on the internet. Although the charges are serious and inexcusable, there is considerable exaggeration in the reporting of the story.

    For instance, they didn’t reuse needles on patients.  They reused needles used to deliver drugs into I.V. lines.  The needles in question never touched a patient directly.  Still not an acceptable practice but, in my opinion, not likely the source of patient infection.  

    They used multi-dose vials on multiple patients.  That’s what multi-dose vials are designed  for.   However, multi-dose vials aren’t supposed to be brought into operatory where there is a small chance they may become contaminated with germs.  Also, multi dose vials expire after 28 days, once used.

    These are relatively minor flaws but that does not obscure the truth: that there was a serious  breakdown in sterilization procedure and it will probably be the worst incident in U.S. dental history.  At the end of the day, a good number of people will become infected with a serious disease at no fault of their own.

    One damning point in the State complaint was the habit of an extra dip in bleach for instruments used on high risk patients. This is unusual because a properly running sterilizer will kill anything regardless if the patient is high risk or not.  This action  illustrates  that the surgeon lacked confidence in his sterilization protocol.  Dipping instruments is not a generally accepted or best practice.  Bleach is a great disinfectant but I don’t like it  because it takes time to kill and it  corrodes metal instruments.

    A second damning point was the lack of spore testing of the sterilizer.  California law requires weekly spore testing of our sterilizers.  Spores are the hardest germs to kill.  Spores are placed in the autoclave and afterwards, sent to a lab for kill verification.  There is no doubt that our autoclaves work.  

    What we do

    As technology evolves, we regularly reevaluate our systems for dental treatment. We have to identify the new technique and buy the correct instruments.  One factor that is considered is the instruments ability to be sterilized.  We only use instruments that can be autoclaved which is stainless steel and some plastics or we use disposable.  Some devices are made out of common steel only. Those devices may work well but they’re out.   We find a substitute device or substitute technique.  

    1. Doctor inspection.  Prior to use, the doctor inspects his instruments.  If one is defective, the instrument is pulled out for replacement or repair.  Sterile substitutes are kept in stock. 


     

    2. Presoak.  Dry instruments are harder to clean.  Presoak keeps instruments wet. This is our sterilization room.  We work from right to left.  Next to the presoak basket is the Sharps container and the smaller amalgam waste container.



    3. Ultrasonic.  This model is the biggest one Whaledent makes.  It cleans via air bubbles in a cleaning solution hitting the instruments with force.   It pits foil in 20 seconds.  In the old days, instruments were scrubbed by hand which was inefficient and not as thorough.  Today, best practices call for an ultrasonic or an automatic instrument washer.



    Aluminum foil after 20 seconds in our ultrasonic cleaner. 

    4. Rinse, dry, inspect and bag.
     



    5. Sterilization.  Our autoclaves are rebuilt Pelton Cranes from the 1970’s.
    We have had newer sterilizers that have died and during its life has had expensive repair bills. I like these old timers.  The internal electronics have been replaced.  They are old, not good looking but reliable, with heavy metal parts and minimum electronics.  The Army used to drop these guys out of airplanes and they still worked. Autoclaves use steam and pressure which is harsh on any machine so beware if the machine is made with light metals and has an abundance of electronics.    

    6. Put away instrument bags and kits.



    7. Spore test.  The little blue envelope holds the spores.  The binder holds a year's supply.  



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    Posted by Gerald Au on Apr. 15, 2013

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    Busted Teeth

    A friend mentioned a story about how his mom fell, knocked her tooth out and placed it in milk until she could receive medical attention.  The milk strategy was a smart decision then but I was wondering if it’s still state of the art treatment in 2013.

    After some research, milk remains a good first aid tool only because it’s so readily available.  Saline is ok if someone at home has a bottle of contact lens wetting solution.  With a teenager or a child, the best treatment is to reinsert the knocked out tooth back into the mouth.  

    If a tooth gets knocked out, call the office, get here within a hour and don’t let the tooth dry out.  Soak the tooth in sterile saline solution.  Milk or plain water are the 2nd and 3rd best options.  The younger the patient is, the sooner the patient can report to the clinic, the less desiccation the tooth is exposed to then the greater the chance of success.  

    However, with an adult, particularly the older adult, restoring the space with an implant often would be a better option depending on the above factors.  Regardless, still bring in the knocked out tooth.  We could use it as a short term fix.   

    In private practice, we don’t see too many teeth knocked out.  One reason is that we’re not open on Friday nights but we have seen some.

    Here is a case from earlier this year.  Someone’s mouth meets the edge of a garbage can.  The teeth were pushed out but not knocked out completely.  The lip was cut through and though. 



    We sutured the wounds.  Replace the teeth back into their original positions and brace it with wire attached to the loose teeth and neighboring solid teeth.  Three months post op, the teeth and lips are fine but the traumatized teeth are at risk for future root canals.
     



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    Posted by Gerald Au on Apr. 1, 2013

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    Panoramic x-ray

    We request every new patient have a panoramic  x-ray taken.  It is the one x-ray that does it all.  It can detect cavities, gum problems, broken teeth and tumors.  Currently, the cost is $110.  It’s easy to do and nothing goes into your mouth.  Because it’s digital, the radiation dosage is lower than film and lower than other medical x-rays.  

    The military requires all personal to have one panoramic x-ray every year.  It sounds morbid but the pano is needed for identification.   With a civilian practice, the necessity for dental records to aid in identification is lower.  Still, in 25 years of practice, I’ve twice received requests from the coroner.

    The pano excels with tumor detection of the jaw.  The incidence is low.  However, the ramifications of having a tumor or cyst is great.  



    This is a pano taken this year in our office.  The patient had always been cavity free and had only check up or bitewing x-rays of the teeth only.  We took a pano this year and were shocked to find a cyst associated with an impacted tooth on the lower left side. 



    The red outline shows the extent of the cyst.  The cyst is basically a  hole of the jaw bone.  Half the bone is gone.   The patient is now at risk for fracture of the jaw.   Worse, the cyst is in close proximity to the inferior alveolar nerve or the major nerve going to the lip.  If that nerve is damaged, then there may be permanent numbness to the left lower lip.  

    Fortunately, there is a happy ending.  Kaiser oral surgeons and plastic surgeons in the operating room were able to remove the tooth and cyst without nerve damage.  Biopsy confirmed the cyst was not cancerous.  The patient is now recovering.  


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    Posted by Gerald Au on Jan. 14, 2013
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    Mexico

    Last month, my family went on a cruise to Mexico, leaving from LA.






    This reflection off a mirror shows off the tiny cabin. There's room for 2 twin beds (two more beds that come down from the ceiling), a desk and small refrigerator. Behind the desk is an open closet and the bathroom. it is so small that while the family slept, the only available space to read was the toilet.  The lesson is that you don't need a lot of stuff.  Four people can survive in 1 small cabin with 1 suitcase each plus a camera bag.  Yet we're able to eat a lot, watch movies, read a book, play Bingo, go to the Casino, attend a photography course, play basketball, run a few laps around the ship, swim, take a bunch pictures, see some sights and go geocaching. My phone's kindle app has a book called Miss Minimalist. She's a fan of downsizing, decluttering and simplifying and so am I. My thought is a cluttered desk leads to a cluttered mind and to be an effective clinician I want the least amount of clutter. Right now, my desk is okay. It's the back counter that's in chaos with piles of journals to be read.  Unfortunately, you get frozen from cleaning up by " I may need it just in case" syndrome.  One can only dream.






    We arrived in Puerto Vallarta on Christmas day.  They have a boardwalk along the ocean, the Malecon, with  an assortment of sculptures. It was fun to walk in 80 degree weather and pose with the  sculptures.  The cool thing was the locals were doing the exact same thing. It's a nice thought that we can go and share the same space as the Mexicans instead of hiding in our own little safe enclave and even though we come from different social economic backgrounds, at the end of the day, we all want the same thing: to enjoy the day and to have a better future for the kids.





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    Posted by Gerald Au on Jan. 7, 2013
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    A Dental Implant Case


    Happy New Year.

    This is a step by step narration of an implant case completed at the Newark Dental Center.


    This is the before picture. Tooth #20 was removed 6 months earlier.




    The gums is lifted off the bone to expose the bone.  I drill a pilot hole.  A pin is inserted into the hole to check its orientation. The goal is to place the implant at the right angle and in the right spot in 3 dimensions:  up and down, side to side and front and back. 


     

    The implant is being held by a dental drill.  The gray thing at the top with threads is the dental implant.  The green thing is the transfer - a temporary device screwed into the implant to hold it.   A bur on the dental drill engages the transfer.  


    The implant is screwed very slowly with the dental drill into the osteotomy or the hole in bone. The implant is turning at 15 revolutions per minute or 1/2 as fast as a LP record on an ancient phonograph. 


    The implant is completely in bone with the transfer sticking out of the bone. 






    The transfer is removed showing the implant in bone.  The top of the implant show a hex shaped cut out in the implant.  Inside the hex is a threaded channel for a screw.  


    A green bolt or healing collar is screwed into the implant.  The gums are repositioned and sutured together.  The gums will heal around the healing collar forming a perfect circular opening above the implant.  

    3 months passed to allow for tissue healing and maturing.  At completion, the implant osseointegrates or fuses to the bone.  Imagine a wood screw in your house.  After 20 years, you could back out that screw with a screw driver.  Not so with an implant, once the implant osseointegrates, backing out is no longer possible.  An impression is taken for a new crown.  The picture shows the temporary crown.  Waiting times after implant placement ranges from 3 to 6 months.  


    The green metal thing is a titanium abutment screwed into the implant. The implant is the body.  The abutment is the head.  The new porcelain crown is the football helmet that goes on top and around the head. 


    This is the finished case 4 months after implant placement.

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