Most patients seem to trust their bodies to tell them when they have a cavity.  So, many times, new or emergency patients come in to see me because they have a mild sensitivity in a tooth and they think they have a cavity. Most often, this mild pain is not caused by a cavity, but by some other minor problem. However, many times, a thorough exam to determine the cause of the pain reveals small to moderate cavities in other areas of the mouth which are absolutely painless.

For all these years, I really thought that it was obvious to most people that only “really big” cavities caused pain. Recently, I mentioned to my wife of 30 years that patients don’t understand that SMALL TO MODERATE CAVITIES don’t hurt! They don’t even hurt just a little- they don’t hurt AT ALL!  Her own shock and amazement at this fact has finally made me aware of how widespread this false belief really is. After all, she is a highly educated woman who has been involved in a dental practice for 34 years. If she doesn’t understand the painless nature of most dental cavities, how can I expect a normal patient to understand this fact. And, after doing a random poll of several other friends and acquaintances, I realized how widespread this false belief is.

Of course, over the years, I have been continually asked by patients why they didn’t feel any pain from the cavities I had just diagnosed in their mouth. I always patiently explained that cavities usually do not cause ANY pain until they get huge! In fact, many patients have told me they thought their previous dentist “ripped them off” because he/she did some filling on teeth that they weren’t feeling any pain in.  I only recently realized how common this belief is and how much extra money and time it is costing patients. It costs a lot less to treat dental decay when it is small vs when a cavity gets large enough to hurt!

Even though I was so slow to realize how widespread this false belief really is, I’m pretty sure I understand why it exists. I’ll elaborate on that in my blog tomorrow.

Tooth decay occurs when the pH of dental plaque and saliva reach a certain level of acidity. In a healthy patient with good salivary flow and good oral hygiene, decay is not a problem because plaque does not sit on the teeth long enough to cause cavities and the saliva neutralizes the acid and helps to wash it away. Patients with poor oral hygiene or poor salivary flow are very susceptible to tooth decay (cavities).

It now appears that certain tooth bleaching materials may actually reduce cavity rates and improve gum health.

The most commonly used tooth bleaching agent is a chemical called carbamide peroxide. Besides causing the teeth to lighten, one of the side effects of a 10% carbamide peroxide bleaching gel is to decrease the acidity of dental plaque and saliva. Carbamide peroxide breaks down in the mouth into urea and hydrogen peroxide. The release of urea is what changes the pH of saliva and plaque. The hydrogen peroxide which is released delivers the antimicrobial effect.

Some bleaching agents contain only hydrogen peroxide. While they are effective for tooth whitening, they do not have the same decay preventing effect as carbamide peroxide because they do not release urea. Urea is the chemical that reduces the acidity which causes decay..

The safety and effectiveness of tooth bleaching by means of application of 10% carbamide peroxide using a custom tray are thoroughly documented. Long term use has also been shown to be safe and effective. The only known negative side effect is occasional tooth sensitivity. This is usually easy to control and causes no long term problem for the teeth.

While more research is needed, it appears tooth bleaching (using carbamide peroxide) may have a dual beneficial effect for decay prone patients. Of course, for those patients considering tooth whitening for it’s cosmetic effects, it’s nice to know that bleaching has beneficial secondary effects.

Most patients assume that all dentists are trained in the same way, and, therefore, have the same skills and knowledge. And, in the first four years of our training, this is basically true. We (dentists) all start out with the same basic training. We spend four years in dental school learning anatomy, physiology, pharmacology, and basic dental techniques. I say “basic” because four years is not enough time to teach advanced techniques. It’s also not enough time to give us much experience. We get that when we get out of school. By the way, the training that we get in dental school is so basic that it really doesn’t matter which dental school we go to. Our true skill as a dentist is developed after we get out of dental school.

Once a dentist has graduated from dental school, he/she is free to start practicing by buying a practice from a retiring dentist, or associating with a group practice.  Either way, they are immediately practicing on patients. Some dentists go into the military where they can gain several years of valuable experience treating military personnel before they go into private practice.   Then there are dentists who want to receive extra training and experience by enrolling in a Dental General Practice Residency.  This was my choice after dental school.

A GP Residency is a voluntary 12 month program of intense advanced training and experience. There are a limited number of slots available in GP Residencies, so only a limited number of dental school graduates can get in. There is an application process that involves a review of your dental school grades, recommendations from your dental school instructors, and personal interviews. I did my general practice residency at Denver General Hospital (now called Denver Health) in 1976-1977.  At that time, there were only 6 or 8 slots available for general practice residencies in the whole state of Colorado.  The number of available residency slots has not changed much in the last 30 years, so it is still very competitive.

So, some dentists start treating patients in private practice immediately out of dental school with very little actual experience. They learn on the job. And yes, they learn on you, the patient.  Pretty scary, huh?   The dentists who get their initial experience in the military or in a residency are supervised by other experienced dentists, and where  the patients are receiving free or reduced fee dentistry.

Since I had obtained so much “hands on” experience at Denver General, I felt pretty confident about my skills and knowledge when I started private practice in 1977.   Little did I know how little I knew.   As we all know, we gain skills and knowledge as we gain experience. We all received basic training in driving a car before we were given a license to do so on our own. Yet we all know that the 16 year old driver has a much higher accident rate than the 30 year old driver. Our automobile driving skills improve as we spend more and more time behind the wheel. So it is with a practicing dentist or any other professional. Experience counts!  Just another reason why “Not All Dentists are Created Equal”. Some dentists have more experience than others.

However, experience is not the only factor. There are many 30 year old dentists, that in my humble opinion (IMHO), are better dentists than 50-60 year old dentists I have been acquainted with. This is were the concept of “Life-Long Learning” comes into play.  Once their formal dental education is over, dentists are on their own to learn new skills, keep up with new research findings, and learn the new techniques and technologies.  Some states require a few hours of Continuing Education per year to maintain your license to practice.  But, IMHO, it isn’t enough to even keep you current, let alone become highly skilled. As a matter of fact, the State Dental Board of Colorado has NO continuing education requirements for dentists. In Colorado, a dentist can stop learning right out of dental school and still perform dentistry on his/her patients for the rest of their career.

So, what really separates the “average” dentist from the “master” dentist?  Life-long learning!  And I am proud to say that I am a member a profession that highly encourages dentists to continually upgrade their knowledge and skills on their own, and at their own expense.   And it isn’t cheap. That is another reason why “Not All Dentists are Created Equal”.   Some dentists are passionate about continuing education and some don’t do any.

So, how does a dentist get continuing education?  There are multiple avenues for learning once you are out of dental school.   You can:

• Read journals, listen to instructional CD’s, or watch instructional DVD’s  (there are hundreds published just for dentists), or do on-line learning

• Go to seminars  There are thousands of these available every year and they range from 1 hour to several weeks of 8 hr days in length.

• Take part in group discussions with other dentists on line or in study groups.

Just to give some perspective on the commitment needed to become a master dentist, I’ll tell you about a discussion that I had with a young dentist the other day.   This particular young dentist graduated from a good dental school about a year and a half ago and then did a General Practice Residency in Denver.  He started into dental practice just a few months ago.  He has had a good basic dental education to this point but wants to do what is necessary to become a master dentist.  We were discussing his different options for continuing education to accomplish this goal and he told me that it would cost him about $45,000 over the next few years just to get started.  This will all be out of his own pocket.   Personally, I have spent over 1,000 hours in continuing education classes since I started private practice.  I don’t even want to think about what it has cost me.

There are many other ways for a dentist to obtain continuing education, but I won’t even try to list them all here. IMHO, a passion for continuing education, or lack thereof, is the main reason “Not All Dentists are Created Equal”. Unfortunately, it isn’t common for a dentist to divulge his/her continuing education experience to his patients.  I guess it would be considered bragging by most of us.  But if you do want some idea of how “current” your current dentist is, you might consider asking them about courses they have recently attended, or articles they have read, or on line learning they have done, etc.

Approximately 20 years ago, I started providing professional tooth whitening to my patients when manufacturers perfected a user friendly delivery system and a peroxide formulation that was safe and easy to use. At that time, there was only one kind of whitening system available – dentist supervised tray delivery. After taking a mould of the patient’s teeth, we fabricate a soft plastic, custom fitted tray that adapts intimately to the patient’s teeth and does NOT cover the gums. The patient is then provided with the tray and a 15% – 30% carbamide peroxide gel syringe.

To use this whitening system, the patient places the peroxide gel into the custom tray, inserts the tray into their mouth, and leaves the tray in for 30 minutes. This procedure is used twice a day. The key to getting good results with this method is for the patient to remain motivated. A motivated patient will usually see results in one to two weeks. To get the best results possible, sometimes it may take as long as six weeks.

Since the above method was introduced, slick marketers have tried to introduce techniques that are “faster” or perceived to be less expensive. This includes a one appointment technique where a gel is applied to the teeth (in the dental office), and a specialized light or laser is applied – supposedly enhancing the results and only requiring one to two hours in the dental office. I have used several brands of this technique, and have found the results disappointing compared to tray bleaching. Not only were the results disappointing, the procedure was very expensive due to the amount of time spent in the dental chair. In fact, independent research has shown that the use of special lights or lasers has no effect on the results. The teeth are whitened only because the patient sits still in a chair with a strong bleach on their teeth for 2 hours. Don’t be fooled by slick technology claims for this type of whitening.

Manufacturers have also come out with something that appears similar to the custom tray technique discussed above that can be purchased over the counter. The “custom” trays are made by the patients by heating up the tray, and placing the tray in the patient’s mouth while soft – creating a “mould” of the mouth. The problem with this technique is that the mould allows the bleach to cover the gums – which can create burns and damage to the gums. Since the bleach comes in contact with the gum tissue, the manufacturers can only use very low strength bleach.

Another whitening technique developed is the use of whitening strips that can be purchased over the counter at drug stores. If a patient is highly motivated, these strips can produce decent results. However, they are very awkward to use – they whiten only the front teeth, not the back teeth – and are very slow to produce results. Once again, since these strips must come in contact with the gums tissue, the manufacturers can only use very low strength bleach. Therefore, the patient must use these strips for a long time – continually needing to purchase more strips to get good results. To get results anywhere near the custom tray method provided by a dentist, the cost is almost equal. Plus, remember you are only bleaching the teeth that can be reached by the strips.

Since patients are always looking for inexpensive way to get white teeth, I am constantly being asked about the “whitening” toothpastes that are now on the market. To quote Consumer Reports Magazine, “None of the 41 ‘whitening’ toothpastes we tested did any better to actually whiten teeth than any other toothpaste. We say don’t put the extra money where the mouth is.” And, I concur. I have never seen a patient get any results using a whitening toothpaste.

In summation, after 20 years of trying to improve on the original custom tray technique, I still find this technique to be the most cost effective and predictable way to whiten your teeth. I have had patients use all of the other techniques, and have found that the original dental office fabricated custom tray technique still works the best and is the most cost effective. Anyone can get whiter teeth if they consistently use this technique.