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Beyond the Bite

The Official Blog of the Florida Dental Association

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Trust Your Instincts

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By Dr. Becky Warnken

Occasionally, patients remind us why we matter in ways bigger than we can imagine. I don’t have to tell anyone that 2020 was a challenging year as a dentist and practice owner. We all know that. In the middle of the summer, when COVID-19 cancellations were still very much a challenge in our practices and shortly after the World Health Organization had released a statement saying that routine dental care should be postponed, was one such time.

During this period, I saw a 69-year-old female patient for a routine hygiene exam. I begin each exam by palpating for lymphadenopathy. Immediately, my gut told me something wasn’t right when I discovered her right sublingual lymph node was firm, rigid and markedly abnormal from the left side. The patient had a history of cancer years before. I didn’t want to panic the patient, but I didn’t want her to take this lightly or ignore it either. I finished my exam and then sat her up. I showed her the lymph node and had her palpate it herself. We discussed her history and I stressed that this needed further evaluation. I wrote down exactly what description she needed to give her primary care physician (PCP) of the lymph node when she called to make an appointment. She stated that it hadn’t been more than six months since she had seen her PCP, and that nothing had come back abnormal at her last regular appointment. I assured her that we would just rather be safe than sorry, and she agreed. She called her PCP immediately upon leaving my office.

Two weeks later, my office received a phone call from this patient. She told Sandy at my front desk, “I don’t want to bother Dr. Becky, she is busy. But I need you to thank her for me. I need you to thank her for catching my cancer. I am entering Moffitt now for a workup and I don’t have a lot of time either, but please just tell her thank you.” She started crying. Sandy started crying. When Sandy told me, I started crying. I was devastated that my patient was facing a cancer diagnosis. I was simultaneously so thrilled that she had come in for her routine exam and that I hadn’t ignored my instincts. She’s undergoing treatment and, at our last update, her prognosis was good.

The physician assistant students I teach at the University of Tampa always ask how you know something is abnormal, or when you should insist something has a further evaluation. My answer is always the same: If you aren’t sure, insist that they return in two weeks. If the abnormal spot or lymph node hasn’t changed, then you know it is worth further investigation. However, sometimes you just know something isn’t right and you can usually help the patient realize the same and guide them to further care. Trust your instincts. This is the one time when a patient will be truly grateful your instincts were wrong if it is nothing, and even more grateful you followed them if you are correct.

It is my daily mission to stress to my patients and my peers the importance of our role as essential health care providers. Even in our day-to-day routine, what seems like a mundane exam can save lives. We can change lives with a smile, and we can save lives with a routine exam. As oral health care providers, we are essential and should not be undervalued. You matter to your patients. I pray you never forget it!

Reprinted from Today’s FDA, Jan/Feb 2021. Visit floridadental.org/publications to view Today’s FDA archives.

Why Can’t I Get My Teeth Cleaned?

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By Dr. John Paul, FDA Editor

I hear this question every so often, and I can sympathize with you. I’d like to give you a quick answer that would solve your concern, but there just isn’t one. Health care is a complicated subject.

Without seeing you, I can’t offer specific answers to your questions because every patient has individual conditions and needs. If I can tell you a story about two seemingly similar patients, maybe you can find some answers about yourself.

Jane is 30 years old, has always been fairly healthy, never had many cavities and has no immediate concerns about her teeth. She got a new job with dental benefits and decided now was the time to see a dentist. She scheduled an appointment with an office that seemed popular on social media and local advertising. The staff seemed pleasant and the office was clean. She saw the dentist for a few minutes — he looked at some records on the computer, took a quick look in her mouth, said something to the assistant and left. Mostly Jane talked with staff members who told her about how she would need to start with “deep cleanings,” and they talked about how she could make plans to pay for the treatment. Jane made an appointment for the deep cleanings, but canceled it because she was unsure about the treatment.

She scheduled with my office for a second opinion. We had her X-rays sent from the other office and I performed a thorough evaluation that lasted 20 minutes. We discussed the health of the bone and the gums holding her teeth in her jaw as well as the teeth themselves. There were a few fillings that were OK, no decay and her teeth did not need any other fillings. Her gums bled a little and there was stuff between her teeth because Jane was not the best flosser. The probing depths were all 3mm or less and the bone level was proper in the X-rays. All this was explained to Jane so she knew what a dentist was looking for and what the results might mean. Jane’s diagnosis was gingivitis, with a low risk of caries. The appropriate treatment was dental prophylaxis, which some people refer to as a “regular cleaning,” but is really a maintenance visit to help healthy people stay healthy. I didn’t have complete records from her previous dentist, and I am left to assume I disagreed with their initial diagnosis and treatment plan.

Bill’s also 30 years old, never had a cavity in his entire life, but he was concerned about his bad breath and wanted to get his teeth cleaned to take care of it. I spoke with Bill about how we would review his mouth and teeth. We examined his entire mouth, took X-rays and used these results to form a diagnosis. While Bill had no cavities, the space between his teeth and gums measured at least 6mm and bled at every site. On X-ray, the bone loss at each tooth was significant and most of his teeth were loose. His diagnosis was advanced periodontitis. I referred Bill to a specialist, though he did not go. A year later, Bill came back to my office and without treatment, the disease had advanced. We ended up pulling 28 teeth that had never had a cavity because the bone was too diseased to hold them in his mouth.

From the outside, both patients appeared to be about the same — successful young people without much history at the dentist and no serious concerns. They represent two extremes of what I see in my practice, but I see someone who could be Jane and someone who could be Bill nearly every month.

When choosing a dentist, you may want to call or visit more than one dentist to find the right match for you, as dentists and practices often have different styles to fit patients’ distinctive needs and personalities. Ask trusted friends and family for recommendations or visit floridadental.org/public/find-a-dentist to find a Florida Dental Association member dentist near you.

The Need for Speed

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By Larry Darnell, FDA Director of Information Systems

Twenty-eight years ago, I worked for Florida State University and I remember when the campus IT gurus hooked us up to something called the “backbone” of the internet. I had the fastest internet connection I’d ever seen at 1 Mbps (1 megabit per second or 1,000 Kbps [kilobits per second]). Crazy thing is, there was nothing to do on the internet back in those days. I’d go home and use an old school dial-up modem at a “blazing” 14.4 Kbps speed to look at my five AOL emails. I was jealous of the connection I had at the office. My, how the tables have turned. In 2020, I have a faster internet connection at my home than I do at the office. The internet of things (IoT) means almost everything at my house is connected to the internet. Who knew that my blender would need to be connected to the internet one day? Everything being connected to the internet (a tenet of IoT) requires a lot of speed and bandwidth to work.

This term bandwidth is like asking if the pipe is big enough for your data. In theory, more bandwidth equals more speed. Ever see the buffering delays? Yep, not enough bandwidth either coming or going. The same now applies to your office. Digital transformation has led to all things electronic: phone calls, practice management systems, cloud-based backups, X-rays or cone beam CT scans that need a lot of bandwidth to store, save or use, so you need to make sure your internet speed is sufficient for that need. That’s usually measured in megabits per second (Mbps). At the office, my personal usage is 120 Mbps while at home it’s more than 300 Mbps. How do I know these numbers? I don’t just rely on what my internet provider says I have. Neither should you.

Most internet providers have tiers of bandwidth plans. Whether at home or office, the concepts are the same. I recommend you test out your bandwidth. In a web browser on a computer that is “hardwired” (physically connected) to the internet, go to speedtest.net. Also test it with a device that uses Wi-Fi and see if it’s substantially different. You also can find speed test apps for phones and tablets, and internet providers may have their own incantation of a speed test. At home, my provider is Comcast and they insist I use their version. If the speed is substantially slower than the tier you’re paying for, there’s a problem. For instance, my tier is 300 Mbps. One day, I checked the performance and it consistently was less than 100 Mbps. Not good. I called them, and sure enough, there was an unreported issue and they fixed it.

Two years ago, I went to the Florida Dental Association’s (FDA) Governmental Affairs Office (GAO) and used their computers for a day. Their internet bandwidth was horrible. I investigated it and found that their internet provider was limited by what they could bring into that old downtown location. At one point, the internet cable was run through a gutter! Time for a change. We went to a different type of provider that uses a cable modem, so speed is no longer an issue. Problem solved. I’m sure you seldom think about the speed of your internet connection until you’ve used a faster one. It was that difference that tipped me off that something was wrong at GAO. For them it was “normal”— for me, it was unacceptable.

Here are three takeaways from this:

1. Find out what your internet speed is supposed to be.

Your provider needs to tell you the tier you should expect to be in. You’re looking for a number with Mbps behind it.

2. Test the speed over a series of days.

If you use one day, some providers will say it varies based on usage. Try off-peak times, for example, when the office is closed. If you’re info bytes not getting what you pay for, find out why. It could be the internet provider, your hardware, computer or network. You pay for it, so you deserve an explanation.

3. Buy all the bandwidth you can afford.

The need for bandwidth will keep growing and that growth will likely be exponential. We put a high-speed fiber connection here at the FDA that gives each person at least 120 Mbps, even in heavy usage. Our work is dependent on the internet now and that’s not likely to change. Why put in a two-lane dirt road when you’ll need an eight-lane superhighway soon? Every two years I go back to my home internet provider and they upgrade my bandwidth for free. This year they did it without me asking!

Bottom line: Make sure you’re getting what you pay for when it comes to internet speed.

Reprinted from Today’s FDA, March/April 2020. Visit floridadental.org/publications to view Today’s FDA archives.

Providing Dental Care for the Patient with Autism

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By H. Barry Waldman, DDS, MPH, PHD; Steven P. Perlman, DDS, MSCD, DHL (HON); and, Karen A. Raposa, RDH, MBA

Autism spectrum disorders (ASDs) are a group of developmental disorders defined by a significant impairment in social interaction and communication and the presence of unusual behaviors and interests. Many individuals with ASDs have atypical ways of learning, paying attention or reacting to different sensations and stimuli. The assessment and learning abilities of youngsters and adults with ASDs can vary from gifted to severely challenged. ASDs begin before the age of 3 and last throughout a person’s life. It occurs in all racial, ethnic and socioeconomic groups.

The Centers for Disease Control and Prevention (CDC) estimated in 2018 that one in 37 boys and one in 51 girls have some form of autism. It is unclear if the increase is due to changes in how one identifies people with ASDs or whether it is an increase in prevalence.

General Symptoms

People with ASDs differ greatly in the way they act and their capabilities.

Social skills: They have limited or no interaction with other people, might not make eye contact and just want to be alone. They may have difficulty understanding other people’s feelings or talking about their own feelings. Children might not like to be held or cuddled. They may not know how to talk, play or relate to other people.

Speech, language and communication: About 40% of ASD children do not talk at all. Others repeat words or questions directed to them, rather than responding. They may not understand gestures. Some can speak well, but have a hard time listening to others.

Repeated behaviors and routines: Individuals with ASDs may repeat actions. They may want to maintain routines and have trouble with changes. Children with ASDs may have significant delays in language, social and cognitive skills, but may be great at solving puzzles or computer problems.

Causes and Treatment

It is suspected that there are numerous causes for ASDs due to complex interactions of genetic and environmental factors. Studies of twins have shown that in identical twins, there is about a 75% rate of both twins having autism, while in fraternal twins this occurs about 3% of the time. The cause of ASDs in most people is unknown, however, it tends to occur more frequently than expected among individuals who have other particular medical conditions, including Fragile X syndrome, tuberous sclerosis, congenital rubella syndrome and untreated phenylketonuria.

Although there is no known cure for ASDs, early and intensive education can help children develop and learn new skills. The goal of these efforts is to help the child to talk, interact, plan, learn and care for his/her needs. While some medications can relieve some of the symptoms, structured teaching of skills (often called behavioral intervention) is currently the most effective treatment.

Associated Oral Conditions

The complex neuro/developmental disabilities compound and exacerbate the all too frequent oral health disorders in the general child and adult populations, including: poor oral hygiene, increased risk for caries, generalized periodontal problems, oral-facial pain, xerostomia, poor nutrition and poor diet.

Dental Services in a Private Practice

The actual technical aspects of care are similar to the delivery of services for the general population of patients. Modifications in practitioner-patient-staff-parent or guardian interactions, however, may be necessary. Providing dental care and ensuring follow-up home care for individuals with ASDs will vary by patient age, type and level of the particular disorder, as well as an appreciation of family/living arrangements. An underlying understanding of patients with ASDs will facilitate the actual provision of care.

  • Not all patients with ASDs are alike.
  • They may be hypo- or hypersensitive to sight, sounds and smells.
  • Nonverbal patients may carry out self-abusive behavioral acts as their only means of expression for pain.
  • You may need to attempt different modalities of behavioral guidance.
  • Additional time may be necessary.
  • Schedule appointments in line with behavioral medication.
  • Keep wait times to a minimum to help reduce anxiety.
  • With proper consent, medical immobilization/protective stabilization may be a necessary behavioral guidance technique.
  • Use simple verbal and nonverbal communication.
  • Use adequate pain control for both restorative and surgical procedures

H. Barry Waldman, DDS, MPH, PhD, SUNY Distinguished Teaching Professor, Department of General Dentistry, Stony Brook University, NY.

Steven P. Perlman, DDS, MScD, DHL (Hon), Global Clinical Director, Special Olympics, Special Smiles; Clinical Professor of Pediatric Dentistry, Boston University Goldman School of Dental Medicine.

Karen A. Raposa, RDH, MBA, Published Author and International Speaker, Clinical Education Manager, Hu-Friedy Mfg. Co., Raynham, Massachusetts

Reprinted from Today’s FDA, Jan/Feb 2020. Visit floridadental.org/publications to view Today’s FDA archives.