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The Dentist's Chair: Pondering a dental procedure in Mexico

Dear Dr. Reitz:
My teeth need to be extracted, and I would like to replace them with implants. I understand it is cheaper to take a vacation to Cancun, Mexico, and have the teeth pulled and implants placed than having it done in the United States. Is there a way of checking on the credentials of the dentist in a foreign country? - Bill, Morgantown

Dear Bill:
You are describing what is termed a "dental vacation": traveling out of the country hoping to save on a dental procedure. To answer your question, I did an Internet search for dentists in Mexico that do implant dentures and combined that with my knowledge of implant dentistry.

As a dentist who does implants, I understand the many options available to a person seeking to replace teeth with implants. They include low-cost plastic teeth that snap over two mini-implants; a hybrid metal-frame, plastic-teeth screw-retained prosthesis over four standard-size implants, sometimes called all-on-four; to the most sophisticated porcelain over precious metal screw- or cement-retained prosthesis over six or more standard-size implants. Before we can compare price, we need to know if we are comparing apples to apples or apples to oranges, as the saying goes.

I discovered on my Internet search that a few Mexican dentists described the low-cost plastic teeth over two mini-implants, but compared their fee to what a U.S. dentist would charge to do a porcelain over multiple standard-size implants, somewhat like comparing a motor scooter to an automobile.

Planning implant dental cases involves quite a bit of time and often the combined efforts of more than one dentist. Measuring the available bone for the ideal size implant to prevent future failure frequently requires using a three-dimensional imaging X-ray machine and consultation between the dentist who will surgically place the implants and the dentist who makes the teeth over the healed implants, often not the same person.

Prior to making your dental vacation plans to a foreign country, sit down with a local dentist and ask for options on replacing your teeth with implants. The dentist should be able to describe at least three different ways to replace your teeth with implants, from the low-cost two-implant overdenture to the most sophisticated porcelain over metal multiple-implant prosthesis. Don't be fooled into thinking dentistry is more expensive in America than other countries.

Dry-mouth remedy spurs tooth decay

Dear Dr. Reitz:
I think it's important for your readers to know the danger of sucking hard candy to compensate for a dry mouth. My longtime dentist retired, so I switched to a new dentist who did a full examination of my mouth, including X-rays of all my teeth. The new dentist discovered that my four lower front teeth have extensive decay and need to be extracted. I told the dentist I place a sugar candy lozenge in my mouth during the day to stimulate saliva. My habit caused extensive damage. Hopefully, this information will prevent someone else from having the same problem. - Bill, Reading

Dear Bill:
Your decision to stimulate salivary flow by sucking on hard candy is very common and very damaging to teeth. I have witnessed many dry mouth patients place sugar candy like Altoids and Tic Tacs inside the mouth to stimulate saliva, only to cause rampant decay on multiple teeth. I still remember my elementary school teacher sucking hard candies all during the school day. I have to assume she ultimately lost all of her teeth from decay.

Chewing gum or sucking hard candy is an excellent way to stimulate salivary flow, as long as they are sugarless. My sweetener of preference is xylitol, because it is not fermentable by the oral bacteria that cause tooth decay. Found in nature and obtained from sources such as birch wood, nut shells and straw, xylitol is similar to other carbohydrates, except the human body does not absorb the available calories as readily.

Xylitol hard candy may help your dry mouth during the day, but until recently there was not a product that helped keep the mouth moist during sleep. A clever new product termed XyliMelts is now available, designed to prevent dry mouth during sleep.

To solve the problem of choking on the lozenge during sleep, XyliMelts has an adhering disc that sticks wherever you place it in the mouth. Just moisten the adhesive side, place it on the upper teeth or gums and allow the XyliMelts to dissolve while you are sleeping to stimulate saliva flow.

My office has recommended XyliMelts to a few of our patients, and so far the reviews have been positive. I was initially concerned the adhesive would come loose, causing a choking hazard, but to my knowledge that has not occurred. This product does not require a prescription and can be found in many drugstores or on the Internet.

A substitution for mouth rinse?

Dear Dr. Reitz:
Why hasn't someone invented a carbonated mouth rinse? My teeth have been replaced with dental implants, and instead of manufactured mouthwash I like to swish carbonated diet soda around my mouth to rinse away food particles and freshen my mouth. The fizz from the carbonation feels like it is eating away the food particles better than most mouth rinses I have tried. - Jimmy, Wyomissing

Dear Jimmy:
Your idea has merit, but the problem is the acidity of the carbonated soda. All carbonated drinks damage natural teeth by causing acid erosion. The degree of damage is dependent on the length of contact and the acidity of the liquid. Dental implants are made of a combination of titanium, porcelain, plastic or other metals, none of which are susceptible to erosion by carbonated beverages.

There is not a lot of research on the most effective way to clean around dental implants, however some recent studies have shown that a water flosser might be the ideal product for cleaning in the hard-to-reach areas under and around implants. In fact, the force of water was more effective than string floss in cleaning around implants. Your use of carbonated diet soda is a unique variation on the tried-and-true water flosser.

Water is neutral with a pH of 7. As a solution's pH value gets closer to 0, the ability to erode tooth enamel increases. Carbonated soda has a pH of around 3, which is certainly more erosive to tooth enamel than water. In fact, there is a documented condition termed "soda swishing" in which individuals swish soda in their mouths until the bubbles are gone to make it easier to swallow. If done for long periods of time, the habit of "soda swishing" results in extensive loss of tooth structure.

I did some research and discovered you are not the first person to suggest a carbonated mouth rinse. A patent is already filed with the U.S. Patent and Trademark Office for a carbonated mouthwash. In fact, swishing carbonated soda has been suggested in the medical literature as an effective treatment to break up that "mucus in the throat" feeling that plagues many individuals.

I suspect designing a dispenser that doesn't allow a carbonated mouth rinse to go flat after opening is the main obstacle stopping production. Since you don't have any natural teeth, I am not aware of any clinical reason you can't use your technique of carbonated soda as a mouth rinse. I suggest you ask your dentist if your home care is working at your next visit.

Dentists also can look for skin cancer

Dear Dr. Reitz:
In addition to looking for problems inside my mouth, my dentist has begun examining my face and neck for suspicious looking lesions that could be cancerous. He said it's not possible to diagnosis skin cancer by visual exam. However, if he finds a suspicious lesion I would be referred to my physician to make the final diagnosis.
I think this is a great service and just wanted to let your readers know that going to the dentist may be more beneficial than just healthy teeth. - Diane in Bernville

Dear Diane:
Dentists' checking inside the mouth for oral cancer has been the standard of care for many years, but only recently have some begun to examine the face and neck for suspicious lesions. It is estimated that one in five Americans will develop skin cancer, which relates to more than one person per hour dying from melanoma. Each year 35,000 people are diagnosed with oral cancer, compared with 1 million people diagnosed with skin cancer resulting in 12,000 deaths each year. Since most people see their dentists more frequently than their physician, the dentist can play an important role in finding suspicious lesions.

Tell your dentist if you have had a persistent mouth sore, difficulty swallowing, chronic sore throat, persistent earache or a nontender lump in your neck. In addition, if you notice a new mole or nonhealing sore on your face or neck, bring that to your dentist's attention. Although it's not possible to identify a lesion by just visual exam, your dentist may be able to determine if the lesion requires a biopsy and either perform the biopsy or refer you to a dermatologist. After a visual screening of the skin on your face and neck, your dentist may palpate the floor of your mouth and the sides of your neck. Swollen lymph nodes can be a cause for concern.

It is believed that most skin cancer is the result of ultraviolet exposure from the sun, so with proper precautions, it is preventable. Avoid long periods in the sun, or wear protective clothing and a hat in addition to sunscreen on exposed areas of your face and lips. Sunscreen is only effective for a few hours, so reapply if you are in the sun for long periods of time.

Dentists are concerned with your overall health, even though their primary focus is on your oral health. I am delighted your dentist is performing a cancer screening. It just makes your trip to his office more beneficial.

Do baseball players need mouthguards?

Dear Dr. Reitz:
My son plays Little League baseball. Last summer one of his teammates was hit in the face with the ball. Fortunately there was no damage to his teeth, but he did require a few stitches to his lip.
None of the players on his team wears a mouthguard. Is there a mouthguard designed specifically for baseball? - Michelle, Shillington.

Dear Michelle:
Baseball is one of the most popular youth sports in the United States, and a relatively safe sport compared with many other athletic activities. According to the U.S. Consumer Product Safety Commission, nearly half of the injuries (44 percent) that occur playing baseball involve the head, with 25 percent to the face, of which 5 percent are to the mouth. Some studies claim 16 percent of baseball injuries to the mouth and teeth are attributed to being hit by a batted ball.

A blow to the face can result in broken, displaced or traumatized teeth. A few years ago I treated a young batboy who had the misfortune to be in the wrong place as a batter was warming up and took a bat to the teeth. His father was smart to call me from the ballfield so I could meet him at the office within an hour of the accident and stabilize his mouth.

Mouthguards in baseball have not received the universal support they have in other contact sports. Currently the only sports that require a mouthguard are ice hockey, lacrosse, field hockey and football. In addition to protecting the teeth from direct trauma, they reduce the risk of concussion to the brain by cushioning impact injuries from a blow to the chin.

My first choice of mouthguard is one made by a dentist. A custom-made guard from an impression is less bulky and more comfortable. If cost is a concern, you can purchase a "boil and bite" type of guard from a sporting goods store or the Internet.

A creative variation on the mouthguard is a product called Bite Tech, which is made by the sports-clothing manufacturer Under Armour. Bite Tech is a mouthguard that claims to protect the mouth and improve athletic ability by opening the airway space.

I am not convinced that the scientific evidence supports the increase in athletic ability from wearing a mouthguard, but the claim may help your son justify wearing a mouthguard to the rest of the team while satisfying your parental concern for his safety.

Defeat gingivitis with proper care

Dear Dr. Reitz:
I brush my teeth in the morning and at night before bedtime. I floss my teeth prior to the nightly brushing to loosen and remove any food between my teeth. My dentist said I have areas of gingivitis. Is there any reason my efforts at keeping my teeth healthy are not succeeding? - Ann, Wyomissing

Dear Ann:
Brushing and flossing are the two most important things you can do to maintain a healthy mouth. But doing it effectively is the key to eliminating gingivitis.

Some studies estimate that 75 percent of adults have areas of gingivitis in their mouths, and I suspect many of same adults brush and floss their teeth regularly. Sticky bacteria - not food particles - growing on the tooth and under the cuff of gum tissue at the base of the tooth is what causes gingivitis.

All toothpastes contain abrasive particles that help remove the sticky bacteria. However, toothpaste is only effective if you get it to the bacteria under the gums, which is where the toothbrush and floss come in.

Many patients ask which they should do first, brush or floss. The correct answer is brush. Begin by taking a dry toothbrush and adding a small amount of toothpaste. In addition to brushing the teeth, work the toothpaste down into the gums around the neck of the teeth. After you have cleaned all four quarters of your mouth, put the brush down and pick up the floss.

Spit out any excess saliva, put a little toothpaste onto your finger and rub it around the quadrant you plan on flossing. That is correct: Toothpaste working with floss is more effective than floss alone, and since it's not possible to put the paste on the floss, you need to put a little around the teeth.

Before flossing the next quarter of your mouth, you may need to add a little more toothpaste by repeating the process of using your finger. If you look in the mirror you will see the toothpaste all around the teeth; just assume some is working with the floss to remove that sticky bacteria.

Initially you may notice some bleeding as your work the floss under the gums. Gingivitis causes ulcerations in the tissue that easily bleed when touched. After two weeks of effective cleaning, the bleeding should stop.

Following these guidelines once a day (my recommendation is prior to bed) should be effective in ridding your mouth of gingivitis. This entire process takes at least five minutes; any less and you are only fooling yourself that your home care is effective.

It's tough to whiten a 'dead' tooth

Dear Dr. Reitz:
When I was a teenager, my front tooth needed a root canal because of an injury. The tooth has always looked darker than the surrounding teeth. Tooth whitening by my dentist made my teeth whiter, but the tooth with the root canal is still dark. Is there a whitening product that can be applied to just the dark tooth to make it the same color as the rest? - Michael, Sinking Spring

Dear Michael:
The pulp chamber in the center of a tooth contains a nerve, which is often injured when a tooth is traumatized. If the injury is severe, the nerve can die and require root canal treatment to remove the dead material. For some reason, which is not fully understood, these teeth often turn dark in color.

The most accepted theory to explain the change in color of the tooth suggests that when the tooth dies, iron is released from the blood cells in the pulp chamber. The dark tooth presents a great challenge to dentists because the stain does not respond as readily to the whitening products on the market.

The current tooth-whitening techniques are based on using hydrogen peroxide coming in contact with teeth for an extended period of time to change the inherent color of the teeth. Although the exact mechanism of action is unclear, it appears the peroxide soaks into the tooth and oxidizes and dissolves the stains.

Since your stain is mainly internal, most of the topically applied products, similar to what you have already tried, don't penetrate deep enough to make a difference. To get the whitening solution where it's needed requires drilling into the back of the tooth and placing the solution inside the tooth. That may sound painful, but remember the tooth had a root canal and the nerve has been replaced with filling material. In essence, the whitening solution (usually 34 percent hydrogen peroxide gel) is placed into the root canal space.

The technique is termed "walking bleach" because after the whitening solution is placed into the center of the tooth, a temporary filling is placed and the patient leaves the office. So the patient is walking around with the solution inside the tooth doing the job of whitening. After three to five days, the patient returns to the office to check the results. It is usually necessary to repeat the process a few times before obtaining the desired result.

Because the tooth had a root canal, tooth sensitivity is never a problem. Unfortunately, a dead tooth is difficult to whiten, even with repeated attempts at applying "walking bleach." In that case, your next option is to have the tooth crowned.

Most medications safe for pregnancy

Dear Dr. Reitz:
I am three months pregnant with our first child. My dentist said I have gingivitis and wants to use Novocain to numb my gums prior to doing a deep cleaning. Is it safe for my unborn baby if I have dental work done while pregnant? - Beth, Shillington

Dear Beth:
Congratulations on the beginning of your journey into parenthood. That trip has some bumps in the road, including an increased risk of gum disease and tooth decay during pregnancy. Your increased levels of the hormones progesterone and estrogen cause the capillaries in your gums to dilate, causing increased bleeding. In addition, if you have morning sickness or acid reflux, the stomach acid in the mouth causes tooth erosion and decay.

If you require dental procedures, you can be comfortable in the knowledge that most of the medications used in dentistry do not jeopardize the health of your unborn baby. The benefit to your oral health by treating your gingivitis greatly outweighs any risk to your baby.

Lidocaine with epinephrine is the most commonly used local anesthetic to numb the mouth; it is also fortunately the safest for you and your unborn baby. Unfortunately, the anesthetic that is usually applied to your gums prior to injecting the needle (benzocaine) must be used sparingly because it has been known to interact with the iron in your blood that carries oxygen, thereby reducing the blood's ability to oxygenate your body.

The antibiotics penicillin and cephalosporin are commonly used to treat dental infections, and are both considered safe for use during pregnancy. Antibiotics to avoid are erythromycin (because it can cause liver toxicity in a pregnant mother) and tetracycline (because it is known to cause tooth discoloration).

As you get into the second and third trimesters, you may find it uncomfortable to sit in the dental chair for long procedures. Lying on your back allows the pregnant uterus to compresses the large vein that returns blood to your heart, which can lower your blood pressure, causing you to faint. So I suggest you ask the dentist to only schedule short appointments or allow you to get up and walk around frequently.

Your baby's health is very important, but neglecting your dental care can result in long-term dental problems for you and your child. A newborn's mouth is free of any bacteria, and most likely the first bacteria it will receive will be from your mouth. A healthy mouth has harmless bacteria that don't cause tooth decay and gum disease.

Patients can help monitor dentists

Dear Dr. Reitz:
Last month an oral surgeon from Tulsa, Okla., was accused of following improper sterilization procedures and using rusty surgical instruments, resulting in a patient being infected with hepatitis C and HIV. I have always assumed that health care in the U.S. was the best in the world, and although going to the dentist is never pleasant, I don't expect it to be life-threatening.
What measures are taken in Pennsylvania to protect dental patients, and how can I be certain my dentist is following proper procedures to safeguard my health? - Michelle, Shillington

Dear Michelle:
In 1998 I had the privilege of being appointed to the Pennsylvania State Dental Board by Gov. Tom Ridge. While also working in private practice, I spent 12 years on the board, the last two years serving as chairman. Compared with most states, Pennsylvania has some of the most rigid requirements to ensure patient safety, some of which I helped to enact. Concerning putting patients to sleep under anesthesia, Pennsylvania established some of the first guidelines in the nation, requiring office inspections to verify compliance.

Rules and regulations can be written, but in everyday practice it requires a dedicated dentist to make sure the rules are being followed. Every dentist is taught to sterilize instruments in a heat/pressure autoclave. Yet for some unknown reason, the oral surgeon in Oklahoma decided to soak dental instruments in Clorox bleach. Every dentist also knows the needles used to inject medications are not designed to be reused, yet that is an additional allegation in the Tulsa dental case.

There is no way to guarantee your dentist is following all the regulations in place to protect your safety. With more than 1,600 licensed dentists in Pennsylvania, the state does not have the money to send inspectors into every office to verify the rules are being followed. For that reason, it's incumbent on you to be observant when visiting any health care facility. The dentist or dental staff member should put on new gloves before working in your mouth. The instruments should be unwrapped in your presence. Plus, don't be afraid to ask about their sterilization procedures.

People want dental care at reasonable rates, but at the same time deserve to be safe when visiting the dentist. Unfortunately, the Tulsa dentist may have felt the cost constraints working within the reimbursement rates dictated by Medicaid and insurance companies and therefore cut corners to save money. Usually, the Pennsylvania State Dental Board learns of a problem with a dental office when a patient files a complaint.