Acrylic dentures ,as a opposed to cast framework partial dentures, are used for patients whose remaining teeth have a guarded prognosis due to mobility, bone loss and /periodontal disease. Patients who are candidates for these often do not want to remove their remaining teeth and may not find implants an affordable option. Since these "transitional" dentures are made from acrylic, adding additional teeth is a relatively easy procedure that involves taking a pickup impression and sending this with the denture to the lab so that they can pour up a new model and add a replacement tooth to the denture. 

These all acrylic dentures are a common choice for patients who don't wand definitive comprehensive treatment but instead just want to replace their currently missing teeth.  

The other day, one of our residents filled out her Rx to the laboratory for fabrication of an acrylic partial denture. These partial appliances are all acrylic with the acception of hand bent wires to help clasp the teeth. These are called wrought wire clasps . They work well and can be adjusted with an three (or two) pronged pliers to fit even better. 

According to vocabulary.com wrought is an adjective meaning shaped to fit by ors if by altering the contours of  a pliable mass (as by work or effort)

Recently, one of our residents filled out her Rx to the laboratory about the fabrication of an acrylic partial denture. she asked for rottweiler clasps.When asked about her doggy dentures she just replied that how she thought it was spelled. I guess she must have missed the lecture about all accrylic dentures. 

 Patients often present with dental pain and would like to get a diagnosis and appropriate dental treatment. They often complain of a tooth ache, which is not very specific, since There can be a number of causes for tooth pain and there are many differential causes.  Often my residients and students try diagnosing using the dental radiographs as their primary tool. Dental radiographs are just one of the items in our tool box. For me , the first thing I do is ask the patients a bunch of questions... When do you have pain? do you have pain on biting, pain after eating, hot or cold sensitivity  or prolonged pain. The answers to these questions have a lot to do with narrowing down why the patient is having pain.  I definitely look at the radiographs to see if their is an obvious problem in the quadrant they are feeling pain( perapical radiolucency or a large carious lesion). 

If a tooth is sensitive to cold it means that it is vital and any teeth with root canals in the area can not be the source of cold sensitivity. Swelling usually means the presence of an infection and the swelling should be palpated to see where it is located intraorally. Pain on biting is a often one of the symptoms and I often will have my patient bite on the wooden part of a cotton tip applicator so they may better localize which tooth is the culprit. Pain on biting can indicate a cracked filling, a large carious lesion or or an infection due to an irreversible pulpitis or necrotic pulp that is causing an infection.

Coming up with a differential diagnosis can be complicated and should involve a trip to a knowledgable dentist. Relying on xrays alone is usually a bad idea. Its best best to have you dentist interview you and check you out in person so that he or she can come up with a more accurate assessment of what type of dental problem is causing your pain.

 Our study club just watched a lecture on how he does examinations of his patients..It makes alot of sense. 'First he goes over problems he sees and gives a tour of the mouth to his patient. Then he explains what could happen if the problems are not addressed. Only after this initial tour does he go over possible treatment options. 

I use a similar approach with my patients. I find that this allows patients to better understand their problems and why I recommend specific treatments. Also the last part of the exam is the cost of various treatment options as well as the pros and cons of each choice.

I find that hearing about cost of treatments , especially if given at an earlier point of the exam can keep my patient from "hearing" my explanations, since once they hear the cost they can fixate on picking an inferior but less costly treatment plan. After all, who wants to spend thousands of dollars completing their treatment. This is especially true if they don't understand the ramifications of choosing their least expensive treatment option. Often I explain that I would probably choose a specific option for one of my own family and this can help my patient understand which plan is most ideal.

Of course finances do play a role in choosing which treatment plan is best for a patient , but I would like my patient to make a truly informed decision, not just solely based on cost. If they opt for the least expensive option they will understand any limitations and risks associated with this most affordable treatment plan. 

 Our office does take a number of different plans. I personally am a Delta Premier Provider and a Cigna Provider. My son David has joined Metlife Dental Insurance. That being said our office a fee for service dental practice that participates with a few dental insurance plans. We have plenty of patients that have plans that we are out of network for, but we bill their dental insurance and then bill them the for what is not covered.

We treat all our patients the same way regardless of which insurance they have. Appointments are usually scheduled for one hour (or two for crown preparations) . This amount of time makes it possible for us to have  sufficient time to ensure a uniform high standard of care. 

Since dental offices need to cover their expenses and make a profit to pay their dentist/owner, some offices have procedures engineered to be done in shorter amounts of time. By this I mean, they try to figure out techniques that are more efficient but hopefully still allow them to produce an adequate standard of care. Some offices succeed and some do not.

When I first got out of my residency in 1981 I worked in a number of "Insurance offices" and while it was good for me to help develop  dental skills and become efficient, I really didn't enjoy playing "beat the clock" ( I am really dating myself with this reference). Now , most days I truly enjoy working at  a more leisurely pace and the dental procedures I perform routinely turn out well with results that are durable and don't cause problems. 

 My son is practicing in my office on Thursdays.. We did our own version of Trading Places. He finished his Mount Sinai general practice residency in June and I started as an attending there on Thursdays and he now works in my office on Thursdays. He has joined Metlife dental plan an is a preferred provider with them and he is in the process of joining a couple of other plans. 

My assistant Jennifer is helping him find where everything is and he is sharing my treatment room with me. He can work on other days as well, but he has filled up his other week days by working in other dental offices. I encouraged him to get experience in a wide variety of dental settings and he has three other part time positions. 

He seems to be enjoying dentistry and he is a fine addition to our dental practice.   I have been thinking about him joining me since he started dental school and am extremely happy to have him join me and my staff in our dental practice.

 

Don't get me wrong... I think having the ability to treatment plan implant restorations has added a great tool to most dentist's tool box, but sometimes salvageable teeth are extracted to facilitate implant placement and a definitive full arch fixed restoration.  I myself do this when the bone is needed to place an implant that will serve as an abutment for a multi implant treatment plan. Sometimes teeth do get in the way. 

That being said, there seems to be an increasing tendency for dentists to advocate the removal of all remaining teeth to fabricate a "hybrid" full arch implant restoration. There is a nasty joke going around about all on 4 implant cases ... they are great unless one of the implants doesn't take or last long and then the entire case can be considered a failure since there is no such thing as an all on three case.

Also many patients are encouraged to have expensive full arch implant treatment cases without empasizing the need for the cleansability of their implant restorations and the importance of adequate patient home care and frequent cleanings at their dentist. Implants can develop peri implantitis , a condition similar to periodontal disease. This is characterized by progressive bone loss around an existing implant.

Sometimes its better to kick the can down the road for many patients, even if it means they will have a partial or full denture made. Maxillary full dentures can be very satisfactory if made well and can be highly esthetic and their fabrication rarely breaks the bank or requires a patient to take out a second mortgage on their house.

All on 4 cases can be wonderful but they are expensive and if they don't stand the test of time, most of the patients will either end up wearing a full denture or spending more money in a second go around since it will be necessary to have and additional implant(s) placed and a new temporary and permanent bridge fabricated. 

 Probably because I currently see patients in three settings I see a whole lot of different patients from varying socioeconomic backgrounds.  The patients who I see in my private practice and who buy into preventive maintenance and good home care do very well and even into their nineties have most of their teeth. The patients I see during my teaching tend to have less money allocated to their dentistry and have mouths that are missing more teeth. Also they are more prone to severe bone loss due to ongoing periodontal disease.

It is not terribly uncommon for a patient at one of my days spent teaching to come in with a mouth full of loose teeth that probably should be removed. The other day one such young patient in her thirties came in and had been told by her dentist she needed to have her teeth removed. Sure enough they all were loose without good bone support. Sooner or later her teeth will fall out or get infected. She explained that she was very attached to her teeth and would like to save them but unfortunately There is no cure for her gum disease and no predictable way to grow bone around her teeth either.

This seems to be a dilemma facing many patients from disadvantaged backgrounds who may only go to the dentist when a tooth is hurting them and the sad end result is that many of these people end up wearing dentures, either partial or full because most can not afford implant supported replacement teeth. This dental tragedy probably could have been avoided if they had been taught properly how to care for their own teeth at home and have a good cleaning at least once per year. Instead our profession has let them down since all too often dentists can be focused on restorative procedures rather than preventive dentistry.

Educating our patients and helping them understand the importance of proper home care, proper diet and appropriate and timely dental care is one of our most important functions as dentists . We are,after all, physicians of the mouth and it is our primary duty to truly help our younger patients maintain their oral health. No , not all dental problems can be "fixed" but instead are handled by us. Hopefully we do our best but no amount of "fixing" beats preventing the problem in the first place.

In general good quality patient dental care should be about helping our patients achieve the best dental care possible. This doesn't necessarily entail getting our patients to spend maximum money. Instead it is about our ability to educate our dental patients about the factors that can undermine their dental health and lead to tooth loss. Most times tooth loss can be prevented through early intervention and patient education about the importance of home care and showing them how to achieve optimum dental health. 

Most often  dentists do not get paid for the time spent on educating our patients. Instead there seems to be an increasing emphasis in health care about achieving efficiencies. and insuring our ability to generate a profits in spite of the ever increasing costs of delivering  dentistry in an optimal fashion.

In my opinion our government and the insurance companies bear a certain responsibility for these developments. Both the government and the insurance  companies seem to be emphasizing efficient and affordable health care which is fine, but let's not throw the baby our with the bath water... Our primary responsibility as dentists is to do no harm and do our best to help our patients maintain dental health. The hippocratic oath never mentions efficiency or affordability. 

Sometimes it seems that many of the  "mandated" courses that I am forced to take to stay credentialed involve the principal of preventing law suits and or fines from the government, but actually have little to do with insuring that my patients receive the best dental care possible. 

As an Instructor at NYU College of Dentistry I remain in contact with many young dentists who are just starting out and many report the pressure they are under from their employer to be productive as possible and to support aggressive treatment plans. While this may make sense to their employers who want to maximize profits, it has nothing to do with the ultimate well being of their patient's dental health , especially if they are not allowed enough chair time to provide optimal dental services.

Personally, I believe the public would be better protected by our government if it spent more time analyzing out comes and quality of care and less time spent on posturing about protecting the public and paying lip service to affordable healthcare. 

When I went to dental school shadowing was not required. My only experience was as a patient. When I started dental school I was surprised how "difficult" dentistry could be. After all, my uncle was my dentist and he always made my care look easy. I had a lot to learn when I started school. I am not sure if I fully understood the difficulties involved with running a practice, seeing patients and making them happy. If I had shadowed I would have had a much better understanding about what is actually involved in being a practicing dentist. 

 David finishes his general practice residency July 1rst. Even though he has passed all his licensure exams, He has to wait one -three months for his NYS license. Accordingly he will join our practice in September and probably be seeing patients primarily on Thursdays. He may see pattients on additional days if he is available. 

Clearly my staff, myself and David are excited for him to join us and many of my patients are asking me about Davids plans. Many of them have known him since he was a small child who often came to my office to visit us. I would dress him up in a smock , gloves and a mask and introduce him as "Dr. David" 

Although it was a "secret fantasy" that someday he would become a dentist, I never really promoted this to David and it was his idea to become a dentist like his father. I couldn't be happier with his progress and look forward to working side by side with him over the next years.