By Lee Ann Brady, DMD 

Cleaning the larger gingival embrasures around a posterior dental implant can be a challenge for patients. In my practice, posterior implant patients are some of the individuals we give X-Floss samples to try at home.  

X-Floss is a dental floss made by iDontix® that is designed to make flossing easier for individuals with bridges, braces, implants, or larger-than-normal gingival embrasures. It resembles yarn, has a thick texture, and has a hard end, making it easy to push under orthodontic wires, bridges, or in embrasure spaces. It effectively cleans larger spaces while remaining gentle on the gums. The soft material minimizes the risk of injury during flossing, even in subgingival areas, and it is conveniently available on Amazon and in drugstores.  

There are two varieties. Green X-Floss from is too thick for some spaces. Blue X-Floss Lite is less thick and just right for some spaces. You and your hygienist may want to give samples of both to your patients to try. Some of your patients are likely to more effectively and consistently floss once they are using this type of floss.  

By Lee Ann Brady, DMD 

When you are managing the care of an older patient, I encourage you to take time to look up their medications and the medication you are considering prescribing, even something as simple as antibiotics or pain medication. 

A resource I use when I am writing prescriptions and also managing existing pharmaceuticals that my older patients are taking is the Beers Criteria published by the American Geriatric Society (AGS). The AGS Beers Criteria® lists the Potentially Inappropriate Medications (PIMs) that are typically best avoided by older adults in most circumstances or under specific diseases or conditions.  

Some listed PIMs should not be written for people over age 65 and some are okay with caution or in moderation. There is a long list of medications people can take until they are ages 65 to 70 without a problem. After that age, there are side effects. 

Some of the medications cause adverse reactions on their own or in interaction with other medications. Some of these PIMs are common over-the-counter antihistamines. 

By Laura S. Harkin, DMD  

My dad and I were enjoying our favorite lunch spot years ago when he turned to me and said, “Laura, isn’t it amazing? There’s an incredible sense of trust that our patients have in us. Sometimes, we give our best recommendation for treatment, and it is declined as if it weren’t important or a priority. I’ve recognized that, more often than not, our patients eventually choose to move forward, proving that it was more a matter of timing and circumstance than lack of value.” 

Trust is the cornerstone of our practice. It was transferred from patients to Grandpa to Dad and to me. I do believe that every morsel is earned through guidance, thoughtfulness, and skill. Trust is an entity that requires constant nurturing. In private practice, one should recognize that a doctor’s trust in their patient is equally as important as a patient’s trust in their provider. With synergy there’s the opportunity for optimal health. Even as a child, I had a very clear understanding of the care my dad had for his patients. This feeling is innate and deeply imbedded in me. I imagine that he felt the same.  

I don’t consider myself “a writer,” but I’ve always enjoyed the art of letter writing. I grew up writing frequently to my grandparents and friends and always loved picking out stationary that reflected my personality. Recently, I reread the letters that my grandfather typed on his old typewriter and my oldest brother scribbled on his Grateful Dead CD inserts – crafted just for me. It seems fitting then that I enjoy writing personalized letters to my patients. In fact, I’m pretty sure I salvaged my mental health during COVID by writing “updates” to my patients during months of closure. I digress. 

The letters that I write to my patients are most often in reference to comprehensive treatment. They provide a bird’s eye glimpse of our most recent findings, diagnoses, and treatment recommendations. My older patients, especially, appreciate my thoroughness, organization, and systematic approach to recommended treatment. These letters certainly aren’t handwritten, but the hard copy renders a sense of care that’s transferred from my hands to theirs. We must remember that individuals comprehend and retain information differently. The one-on-one, verbal, treatment consultation can become lost in the shuffle of everyday. Add dental language and complicated procedures to the mix, and that’s simply a recipe for confusion.  

Whenever I present complex treatment to a patient, I write a letter in everyday language to support our conversation. It’s stored in their digital chart as part of their dental record. In my first paragraph, I state my patient’s chief complaint. A summary of clinical findings followed by bullet point. Next, I provide my best treatment recommendation, an appointment sequence, and the financial investment. Photographs are also a helpful insert to aid in explanation for family members who were unable to attend the consultation. I think there’s value in a tangible letter taken home to revisit.  

Treatment letters are also an irreplaceable resource for my team. When a patient calls to schedule treatment previously presented, my stored letter immediately becomes a reference for scheduling appointments, including time allotments and space in-between subsequent visits. In my office, we offer a courtesy for treatment paid in full. This amount is figured in the financial investment portion of my letter so that conversations regarding immediate payment or a payment plan can easily flow. Should a case not be accepted prior to a routine recare visit, this letter serves as an excellent reminder during team huddle. It’s inefficient to page through multiple chart notes and software-driven plans with no explanation of the diagnoses which caused a need for restoration in the first place.  

In my first few years of practice, it was hard for me to accept that I needed to view this document as fluid with a potential need for multiple modifications to suit my patient’s desires and limitations. For example, financial concerns often lead to the need for phased treatment or a compromise from the ideal. I’m committed to openly discussing what may occur if no treatment is rendered or if a compromised approach is chosen. Likewise, I believe in the importance of presenting the financial component of extensive treatment myself. As the dentist and business owner, I must “own” the fee that I’ve carefully determined to reflect indirect and direct time, the skill level and support to be provided by my team, the technical excellence of my laboratory technicians, and my own knowledge. The fee that I present is steadfast, barring an unanticipated need such as root canal therapy. Should there be a need for additional chair-time or visits, it’s included in the quoted fee.  

Finally, my letters include my expectations for post-treatment maintenance. For example, if we are to complete a hybrid case in conjunction with a surgeon, I’m careful to share the importance of periodontal health and frequent maintenance visits to prevent peri-implantitis. In patients who have pre-existing medical conditions that when uncontrolled can be contradictory, I stress the importance of regular monitoring. Ultimately, I strive to empower my patients to choose and achieve oral health, Undoubtedly, oral health positively impacts overall health. My personal letters are a distinguishing trait of my practice that convey the level of care to be carried from presentation through treatment and in maintenance. Consider the value in this extra step! 

By David R. Rice, DDS 

I travel a lot for speaking engagements and often ride to and from the airport using Uber. As I make small talk with the drivers, inevitably they ask what I do for a living. One day, as I shared that I was a dentist, the driver said, “I’m finally straightening my teeth with those aligners.”  

I thought, “Okay, he’s either seeing a dentist or he’s doing this thing on his own.” Either assumption would’ve potentially painted me into a corner, so instead of assuming, I asked a simple, yet leading question: “Good for you. Is your dentist happy with the progress?” 

Leading questions like that help us walk a patient down the path we want. His response was, “Wait a second, this should be done with a dentist?” 

With one question, I got to the heart of the matter. From there, I responded and asked a series of simple (and again leading) questions: “Yes, seeing a dentist helps to know if you are a good candidate to move your teeth at all. How is the health of your mouth? Are your gums healthy? Do you have any cavities?” 

Now he was thinking, “Wow, not only should I be going to the dentist but there are things that could go wrong.” 

I asked him one more simple set of questions: “Would you like to know basic things that could go wrong? Or would you like to know what might really go wrong and harm you?” He, of course, wanted to know what could harm him. 

Simple, leading questions get to the point. So, when restoring a patient, I think about the simplest questions to ask to understand what the patient understands, what the patient really wants, and why. In short, I want to know what matters most to them and connect that to the dentistry I know they need. As an example, I might ask, “Do you want to replicate mother nature when we restore that tooth, or do you want to improve upon mother nature? Would you like to discuss preventing future problems that will save you time and money or just focus on today’s problems?” 

These leading, simple questions prompt a response that enables me to determine if the patient wants just a slice of pizza—say a crown, the patient wants the whole pie—an optimal smile, or the patient wants something in between. Based on that input, I know how to best have a great conversation with the patient—a conversation the patient will appreciate and through which I can earn more trust.  

By Lee Ann Brady, DMD 

One of the most common ways that we temporize a patient who is having maxillary anterior implant dentistry is with an Essix retainer. Some patients will wear it 24 hours a day and others for less. Hopefully they are taking it out to rinse, brush, and floss, but the reality is they are wearing a removable device that covers all of the tooth surfaces for a lot of hours every day, and we’re increasing their risk of caries, decalcification, and gingivitis. 

In addition to discussing the normal oral hygiene to be done at home, in our practice, we typically dispense a product like Clinpro 5000 from 3M or MI Paste from GC America. These are high calcium and fluoride products that provide fluoride treatments inside the Essex retainer. 

• If a patient is sleeping in the Essix, the instructions are to brush and floss the teeth and then use a toothbrush to spread a little bit of Clinpro or MI Paste on the inside of the retainer before going to sleep. 
•  If they are not wearing the Essix during sleep, the instructions are the same but to wear the Essix for up to an hour every evening before removing it to go to sleep. 

If the patient’s caries risk is high, I prefer using 10% carbamide peroxide gel instead of Clinpro or MI Paste. This is the active ingredient we us in perio trays to help prevent gingivitis. This is also the means by which patients can whiten their teeth while wearing an Essix retainer. 

To prevent damage to the Essix, instruct patients to rinse it with cold water and, when not wearing it, to store it in the provided container.  

A while ago, I had the opportunity to repair a small bubble in an old composite restoration, and I got to thinking you might like to know how I use air abrasion to do this type of repair.

I don’t know how many times you see this, but I frequently see small holes in old composite restorations. In many cases, the margins look good. Everything looks good about the restoration except where there was an air bubble when the composite was placed and now there is a little hole on the occlusal surface. Food can get trapped and staining can occur in the hole, but the hole doesn’t descend into the tooth. And sometimes I see a little gap on the margin of an old composite with staining or early decay. In both cases, I don’t want to remove the entire restoration.

I use a lot of air abrasion in my practice, and in particular, I find it is wonderful for repairing old composite. I have the EtchMaster® from Groman. It’s a little handpiece that is super easy and convenient. It makes using air abrasion chairside something you will want to do every day.

Use 50-micron aluminum oxide air abrasion to clean out the stain, etch the old composite, and etch the tooth. If any tooth structure is to be etched, this air abrasion is a replacement for phosphoric acid. So, in one easy step, you have prepped the tooth and the composite. A plus of this technique is that local anesthetic is not needed if the hole does not extend into the tooth.

Now you can go in and use your dentin adhesive and replace your repair composite. Today, dentin adhesives contain MDP or PMMA which is the chemistry we need for the new composite to bond to the old composite. If I were to repair a composite restoration with a handpiece and a burr, I would not get the same bonded interface between the new resin and the old resin.

For both ease, patient comfort, and the best bond, I choose to treat previously polymerized resin with air abrasion and then some sort of resin that contains either MDP or PMMA.

Why Patients Want Early Detection

For more than a decade, there has been an increase in the occurrence of head and neck cancers in the United States. According to the American Cancer Society, over 53,000 people in the United States will be diagnosed with oral or oropharyngeal cancer in 2020. Worldwide, new cases of oral and oropharyngeal cancer exceed a devastating 640,000 people per year.

Head and neck cancers include those occurring in the lips, mouth, tongue, and throat. These cancers are often referred to as oral cancer or oropharyngeal (back of the mouth and throat) cancer. There are two distinct pathways by which most people develop these cancers. The one most familiar is through the use of tobacco and alcohol, and the other is through exposure to the HPV-16 virus (human papilloma virus, version 16). HPV-16 is a more recently identified etiology and the same one that is responsible for the vast majority of cervical cancers in women. In less than 7% of oral cancer cases, there is no known cause, and it is believed that these cancers are related to a genetic predisposition.

While oral and oropharyngeal cancers are still considered uncommon, The Oral Cancer Foundation reported in 2019 that approximately 132 people in the US are diagnosed each day and one person dies from oral cancer every hour of every day. This sobering statistic has not improved in many years. The most recent statistics reported by the American Cancer Society indicate there has been an ongoing rise in cases of oropharyngeal cancer linked to HPV infection in both men and women.

Oral cancers have an 80%-90% survival rate when found at early stages. Unfortunately, the majority of oral cancers are found in the late stages and this is the reason for the very high five-year death rate of 43%. Late-stage diagnosis is said to be a result of many complex conditions including a lack of public awareness and a lack of professional screenings in dental and medical offices.

Automatically Include Cancer Screening

Within your exam fee, I urge you to include a thorough oral cancer exam. Make sure your patients know the screening is automatically included in your new patient and regular exams. While performing the screening, talk about what you are doing and why. Patients are becoming more and more proactive about their health and are more than pleased to know about the inclusion of the screening. This is a health-centered benefit of your practice that will distinguish you. If your patients are aware that you are doing it, they will mention it to others and their confidence in you will grow.

Another Opportunity to Engage New Patients

My friend Linda Miles, co-founder of Oral Cancer Cause, says, “During the last few years of my teleconsults, I encouraged each dentist to develop a strong relationship with their local oncologists, radiologists and ENT specialists so that he or she would become the go-to dentist to do dental clearances for all cancer patients especially the head and neck cancer patients. In order to start radiation or chemo, all pending dental treatment must be completed. This ranges from hundreds to tens of thousands of dollars per patient to the practice. Dental Oncology is a growth path many should develop.”

It used to be a challenge for me to help patients who came in with recurrent aphthous ulcers, lichen planus or erosive lichen planus, burning mouth, burning tongue, or geographic tongue that was uncomfortable. I’d worry about the pharmaceutical reactions of prescription options such as prednisone, steroid mouth rinses, and lidocaine rinses. Now, that challenge is greatly reduced due to the success we have had treating these problems with nonprescription topical antioxidants. 

There is a group of nonprescription topical antioxidant products that I rely on weekly from PerioSciences. These products not only promote healing but also provide significant relief from soft tissue pain, xerostomia, and burning sensations in the mouth. This is PerioSciences’ AO ProVantage line of mouthwashes, gel, and toothpaste. They are without a doubt the best products I have come across in my career for oral medicine applications. They were developed by dental scientists and other researchers and contain two antioxidants from the skin of apples. The products are marketed to help with a number of things in addition to oral wound healing, for example, to treat superficial gingivitis and to maintain patients who are at advanced risk of perio inflammation.  

In my practice, I have two patients who have chronic erosive lichen planus. We discovered that the application of the AO ProVantage gel to a lesion, four or more times a day, allows the body to heal the lesion. Within three to four weeks, the lesion is gone completely. After lesions are gone, my patients stop using the gel and start using AO ProRinse three to four times a day to prevent the outbreak of another erosive lesion. If they get another lesion, they go back to using the gel. The mouth rinse has reduced the number of outbreaks for these patients, and having these products on hand, has allowed my patients to successfully manage outbreaks on their own. 

I have lots of older patients who suffer with burning mouth or burning tongue. AO ProRinse mouth rinses have worked well for them. Some of my patients have severe dry mouth in association with the burning—some with Sjogren’s syndrome, some with Lupus disease. We start them on the hydrating formula of AO ProRinse, and they rinse their mouths four to six times a day with remarkable results. It’s also been of great value to my patients going through chemotherapy to keep their mouths hydrated and comfortable.  

The PerioSciences products are nonprescription and now readily available via Amazon. Once introduced to the products and given guidance, my patients have found it easy to determine when to start using the products and how often to use them. Topical antioxidants are just one more example of industry breakthroughs I am grateful to have in my clinical toolkit and widely available to patients.  

When it comes to diabetes, let your patients know about the impact oral inflammation can have on their health. Explain what you can do to help them and what they can do to help themselves. Clarify what they can do to take control so that they can live happier, longer lives.

Give your patients optimal assistance.

Include questions in your health interview about whether the patient has been diagnosed with diabetes, has been counseled about being at risk (prediabetic), and/or has a family history of diabetes. If your patient affirmatively answers to any of these questions, inquire about what they know about the link between gum inflammation and systemic diseases, such as diabetes.

Gently, explain why you are concerned.

Even if it is slight, gum inflammation is harmful when chronic. Let them know that among other health problems, persistent inflammation exacerbates diabetes and development of diabetes. It would help to tell them a story about an anonymous dental patient whose blood sugar decreased over a matter of six months and improved again within a year due to the elimination of gum inflammation.

Invite your patients to begin a new oral health regimen.

Let them know that you will partner with them to track their compliance, evaluation, and improvement. Inspire them with a story about another anonymous patient whose oral health and diabetes was improved by starting a healthier regimen.  They too can experience the healing power of making healthy choices and developing healthy habits throughout their life.

Your patients will start to report to their physicians, family, and friends about the conversations you have had with them. They will all be able to see the efforts you are making to control inflammation in their mouths, and the evidence of improved health. You might begin to see referrals from these patients and their doctors start to follow.

In the Pankey Institute’s Invisalign focus course, course leaders invite you to consider the ways in which Invisalign can be used to enhance what you do for patients on a daily basis.

One of the most significant benefits to be gained from Invisalign is achieving a more optimal environment for eliminating gum disease and maintaining periodontal health. Another is the preservation of natural tooth structure.

In my position as Director of Content for Patient Prism Academy (at www.patientprism.com), I work daily in helping dental teams communicate with their patients and prospective patients, and sometimes even among themselves. Knowledge translation is my strength. I’ve made it my business to know what patients want to know. The following information is provided in a form you can easily include in your treatment presentation when discussing dental alignment with your patients.

You know this, but I remind you here. The ideal candidate for aligner treatment is not limited to esthetic cases. Your patients who are battling gum inflammation and inflammatory diseases such as diabetes and CVD, or your patients whose teeth are worn, chipped, crazed, or perhaps even mobile, will be receptive to this particular discussion.

They Just Don’t Know

The ADA has told us that, although 75% of adults (80% of adults over age 65) have some form of gum disease, only 60% have any significant knowledge about it. It’s not surprising, then, that even fewer have an understanding of the association between their dental alignment and the health of their teeth, their dental alignment and the health of their supporting bone and gum tissue, and their dental alignment and their systemic health.

Your Patients Want to Know What Studies Have Shown

• Gum disease has surpassed tooth decay as the leading cause of tooth loss.
• Plaque accumulates more where teeth are crowded.
• Where teeth are crowded, more types of harmful oral bacteria are present in the plaque below the gum line.
• When teeth are crowded, there is increased risk for development of periodontal disease and tooth loss.
• When teeth are crowded, there is increased risk for chronic gum inflammation.
• Even low grade chronic inflammation harms periodontal tissues and systemic health.
• Crowded teeth, in combination with any of the following, increases the patient’s risk of gum inflammation, periodontal disease, and systemic diseases:
  • Tobacco use
  • Diabetes
  • Heart disease

This is to say that, if more than one of these factors is present, the risk to health is even more.

• Gum disease, chronic or acute, exacerbates (makes worse) cardiovascular disease and diabetes.
• Poorly aligned upper and lower teeth put abnormal force on each other. Over time or suddenly, this abnormal stress wears down, chips, or creates cracks in precious dental enamel. The stress can also weaken root support, inflame periodontal ligaments and nerves, and result in loose teeth (teeth that wiggle).

Your Patients Also Want to Know

• Battling gum inflammation, periodontal disease, and systemic disease can all become problematic due to crowded teeth. Until teeth are aligned properly, the personal cost can (will) grow in terms of the extent of treatment needed and the time and expense required for treatment to restore health and quality of life.
• Additional benefits of Invisalign treatment will be a more esthetic smile and proper tooth spacing for restoration of damaged teeth (and replacement of missing teeth if one or more teeth are missing).

Feel free to copy any of this to an information sheet to utilize in your consultations. Because your patients view videos fed from YouTube via your social media, I encourage you to use these bullets to organize your thoughts to prepare a video presentation for patients.