So I took a little hiatus from blogging to take some time to actually enjoy life. Summer is just too beautiful in Vancouver to spend the day inside writing about nerdy things, and I got to appreciate a week long journey hiking the West Coast Trail (photo cred to James Sutton), really getting time to relax and appreciate what is important in life. But..... I was on social media today and saw something that amazed me. Check this out: https://smiledirectclub.com/ Why The Face???????????? Let us talk about DIY dentistry. Our society is absolutely losing all sense of hard work. If there is a short cut or an easy fix, people want it. But life does not work that way. There is no quick way to lose weight and keep it off, there is no magical cure for aging, and dentistry definitely is not something that should be done at home by untrained people. Yet here I see an ad for an at-home tooth straightening system. Who in their right mind would do this? Is there such a disconnect with oral health and systemic health that this is actually a marketable treatment? Imagine someone with scoliosis (curvature of the spine) or perhaps a fractured wrist, would you expect them to order a kit off the internet and make themselves a back brace or a cast? It would be very ill advised. But somehow for crooked teeth it is ok? Ridiculous. Orthodontics is one of the most complicated treatments that dentists can provide; it is not easy to learn the skills required to perform controlled tooth and root movements, and it definitely cannot be predictably completed at home without proper monitoring. Anyone who has worked with clear aligners knows that it is not as simple as putting trays in; buttons need to be glued to the teeth, enamel adjustments are often required, and in many cases elastics and traditional braces are required to properly finish the case. I have spoken to many people who have had clear aligners and are still not happy with their bites.....but their front teeth look great. This is unacceptable. Yes, I understand that dentistry is expensive, but taking shortcuts with one's health will never work out well. Yet for some reason, people think that it is ok for dental care. Well it isn't. I have had many people come to my office after trying the cheap way first only to end up with problems, ones that cost more to fix than if the treatment was done properly in the first place. So is the nature of being a prosthodontist. I am increasingly finding my office to be a fix and repair shop. I know that there are going to be the classic internet troll comments about how dentistry is a scam, and that it is not as hard as it seems, and that we are all in it to fleece our patients. I see those comments on every online article about the costs of dental care. Believe me, dentistry is not easy; it is something that takes years and years of training, and then very expensive equipment and materials (in addition to quality labwork, which also is expensive) to be able to provide high quality dental care. It is not something that can properly be done at home with correspondence with a health professional online. Honestly, when I see these short cut treatments, it makes me question the direction that my profession is heading. Is it all about big business and quick fixes now? I dedicated 4 years of my life to becoming a dentist, and then another 3 getting my specialty training, which was after completing a bachelors degree. I have also sacrificed quite a bit to put together my little practice. I know how hard it is to provide high quality dental care, and expect nothing but that for my patients. For someone to come out and make people think that it is something that can be done at home belittles everything that I, and other dentists and specialists, have worked for. But I guess there is always a market for people who want things done quick, cheap and dirty. If you are considering a quick fix like do it at home braces, please take the time to research your other options, including the best one, which would be to consult with an orthodontist. It will be worth your time and money. Thanks for reading! Dr. Dave drdave@alfaropros.com #DIYDentistry #Invisalign #Braces

So another nerdy dental blog....sorry guys. Kristie and I have been putting together some quick videos in the office of our Trios 3 digital impression machine and to my surprise, they have actually been viewed quite a bit, so I figured that I would let you know about the system itself. It would be boring to put all this information in a video. Let us talk about the Trios 3 scanner. What are dental impressions? I am sure that many of you have suffered through the traditional goopy pastes and bulky trays that are required of traditional dental impressions. Whenever we dentists need any dental labwork, we must send an accurate representation of the dentition to the lab tech, and that is still usually done with impression material. There are a whole bunch of different materials that we can pick from depending what we are trying to do, and each one has advantages and disadvantages. Having traditional dental impressions made is not the most comfortable experience for patients, and it sometimes takes a couple of tries to get things just right.......especially if your dentist is picky about results. What are digital dental impressions? Dentists can now take impressions with the use of intraoral cameras, and no longer need to rely on these pastes! This technology has been around since the late 80's, and has been primarily utilized in "crown in a day" applications. Today's scanners are much more versatile and can used for a whole bunch of dental treatments. The scanners usually consist of a "wand" or "gun", which is the actual camera component that captures the images. There is a huge range of systems out there; some capture still images one at a time, others capture a rapid succession of still images, and some capture data in video format. All of the systems use some sort of algorithm to stitch the images together to create a 3D model of the teeth and gums. I have done a lot of research on digital scanners as it was a major component of my masters thesis and I have worked with a bunch of these systems. As a prosthodontist, I am often completing dental treatments that are more complex than a single crown, or a single implant, so I was hesitant to get a scanner because historically they had limited applications. But things have changed. The new scanners are versatile, fast, and easy to use. Here is the Trios 3 in action: Why did I pick the Trios 3? Even with all of the scanners that are available on the market, when I decided that they had advanced enough to be used in a Prosthodontic office, I did not hesitate to pick the Trios 3 as my first choice, even with the hefty price tag. I looked into at least a half a dozen other machines before picking this one. I love lists. Let's make a list of pros: 1. Full colour: There is nothing better for patient education than to be able to show them a full colour, 3D image of their teeth, gums, and bite, in a manner of minutes. During our consultations, Kristie will scan the patient (5 minutes), and we can review the findings right away. It actually has a "wow" factor. Patients can really see what is going on and are amazed by the technology. Previously, to complete a case presentation, a patient would have to return to the office at a later date because we had to get models poured and I had to crop and edit photographs. It is done now for me by Kristie in less time than it takes to make a couple of alginate impressions. This may not be a benefit that can be measured on a spreadsheet (for those crunching the numbers to see if a digital scanner will save you money), but it is truly an invaluable asset to have the technology. Shade matching has been surprisingly accurate. The lab gets so much information and you can overlay HD images in seconds. I know there are skeptics of it, and I was one of them, but the results are pretty convincing. 2. No Powder: Various machines on the market still require the use of a powder spray on the teeth before scanning. This is unacceptable because it really affects ones ability to predictably start and stop the impression. Once you powder the teeth, if the patient brushes off powder with their tongue or cheek or even if the dentist or assistant does so while scanning, the field has changed. Most reps say that this is negligible, but for me that is a major problem. The Trios 3 has no powder at all so we can start and stop the scan whenever we want, which is great when you encounter people who have strong pharyngeal reflexes for example. In fact, we can even begin the scanning one day and complete it another. People often come in on an emergency basis with something broken. If we do not have time to see them that day, we can easily squeeze in a five minute scan and get whatever we need for the next appointment. Furthermore....that scan can then be the basis of our crown or bridge impression, so all we need to do at the next appointment is scan the abutment once it is prepared, which takes 15 seconds. It has done wonders for our workflow. 3. Bite Registration This is where I was skeptical about any scanner. How accurate is the bite really going to be? It takes this scanner under 20 seconds to "take a bite" and the results have been amazing. With the ability to send the lab a pre-preparation scan, the bite registration is made before any preps are made, and the original occlusion can be used as a model for the future crown. My insert appointments are much shorter and I often do not even have to do any adjusting. I have only had to send back a couple of cases all year; a much lower rate than with my traditional impressions. Furthermore, it is so fast that there is no reason to not send full arch impressions every time. How many of you are still working off triple trays to save time and money? This is a much better option. Take a look at how quick it is: 4. Virtual Articulation Trios 3 is made by 3Shape, which is a major player in laboratory technology, and they make both hardware for lab scanning, and software for 3D design and milling/printing of all sorts of dental work. Being such a design based platform, 3Shape has virtual articulators for pretty much every brand on the market. If you use a Panadent, or SAM, or a good ole Hanau articulator, the lab can set up your case on a virtual articulator with the settings that you prefer. I honestly don't go that far for most cases, but the option is there if I need it. Talk to your lab. What do they use for their CAD/CAM design? I bet it is 3Shape.....so why not send them a file that fits right in? Oh.....and it is not a closed system so it can go to many programs in case they are not using 3Shape. 5. Evolution This is the hardest thing about keeping up with technology nowadays. You buy something, and before it is delivered to your office, there is something newer, hotter and better out. It is a tough pill to swallow when you are dropping mega cash on a specific technology. 3Shape is software driven. They have designed the scanning systems to be able to have the software upgraded so you can be running the latest versions on older versions of the scanners. For example, 3Shape recently released an update for Trios 3 scanners called "insane speed", which sped up the scan time to a truly unbelievable speed. This update was also available for the previous Trios model, so even though people are using an older scanner, they can reap the rewards of the software advances. 6. It is just easy and versatile You just have it to try it to really understand. The software is quick and intuitive. It is really easy to fix mistakes if you have say, marked the wrong tooth prior to scanning, or decided that you want to do a crown instead of an onlay, or found an undercut or a spot on a margin that you want to fix. There are so many fancy features during scanning that it would take multiple articles to explain. Maintenance and infection control are very simple. And best of all, there is no "retaking" an impression, and you do not have to wait for the lab to pour something up for you to evaluate things. And it is versatile. When I posted my first video, one of my colleagues piped up ,"well let me know when you can print a guide, place an implant, and then mill a temporary crown in the same day". Um....I can. I have used the scanner for crowns, onlays, bridges, implants, guides, nightguards, partial dentures, whitening trays, waxups and vacuforms......the list goes on and on. I am even using it for an immediate complete denture coming up. Trios will soon be able to send cases to Invisalign, which is great, because as we know, they are really picky about their PVS impressions but accept virtually 100% of digital ones. The only thing that I have not used it for is traditional complete dentures. I do send things to the lab for manufacturing so I cannot do things "in a day", per se, but if I was interested in using up my valuable time with labwork in my office, I could send files to a broad array of mills and printers, instead of being locked in to one machine. 7. Portability I have the "pod" version, which is a laptop and pod for the wand. I do work at two offices, so I can easily take this machine from location to location without any problems. It sets up in five minutes. 8. Support Whenever I run into a "how do I do that again?" moment, I get instant support. This is essential when learning such a versatile machine with so many features and options. Ok so there have to be some cons. I racked my brain to try to not look so biased, but I really could only come up with two. 1. Price This is an expensive machine. But the more I use it, the more I see I made the correct choice. 2. Lack of milled models Unfortunately, one manufacturer has the monopoly on milled models, which are more accurate than printed models, depending on the printer. This means that you have to actually speak to your lab and find out what they are doing to verify that their printed models are accurate. The lab I use scans the models after printing and then compares them to my original scan to make sure that there is no difference. This takes time and experience to have this level of quality control. And like I said, I have only had 2 cases come back ill fitting. If you use a digital scanner, you need to use a lab that has a grasp on digital workflow. Well, I know that this was a nerdy dental blog again and I bet only a handful of people are going to read this. If you have gotten this far and are in the Vancouver area and want to come check out the machine in action before diving in to the world of digital dentistry, please get in touch. We will be running very casual study club sessions starting in September, where we hope to get everyone to sit down in a clinical setting and check it out for themselves. Digital impressions are here and should become the standard; I am worried that my impression material is going to expire and that stuff cost me a fortune. Get in touch! Thanks for reading. Dr. Dave drdave@alfaropros.com #DigitalImpressions #Trios3 #3shape #nerdy

So I received an email today from a dental implant company promoting a course. It is quite common for companies to sponsor lectures and courses in dentistry, with the ultimate goal being to introduce dentists to their products and services. Business is business, and along the way there is some education. On one hand, this is a great way for dentists to gain experience and to earn those CE requirements, and unlike my friends in the medical field where company sponsored events are really getting cracked down on.......there is usually free food and free swag. But on the other......these courses are getting way too advanced. The email I received today was for a two day course on lateral window sinus lifts. What in the world is that? Let us talk about sinus lifts. When someone has their teeth removed, the tendency is for the supporting bone to "atrophy", or to shrink. Just like muscles get smaller if you don't use them, the jawbone shrinks if there are no forces being applied to them by the teeth. This poses a problem for future dental implant placement, especially in the back teeth area of the upper jaw. Just above the roots of these teeth are the maxillary sinuses. If you have ever had a cold or allergies, this is the area underneath your eyes that feels stuffed up and full of pressure. The maxillary sinuses are air spaces within the skull, that are lined with a membrane. If someone has had a large amount of bone atrophy in the posterior maxilla, one of the options to regain the bone volume required for dental implant placement, is to graft INSIDE THE SINUS. There are various approaches to this, but anyone who has been involved in sinus lifting procedures knows that this is not a minor dental procedure. When there is a large volume of bone required, or if the anatomy demands, the "lateral window" approach is often the technique that is chosen. To complete this, the gums are reflected off of the jaw bone, a chunk of bone is cut away from the jaw exposing the sinus membrane, and then the membrane is pushed up and bone is placed underneath it, in essence making the jawbone taller, thus allowing for dental implants to be placed. This is a complicated procedure with some serious potential risks, including injuring large arteries (bleeding), and perforating the sinus membrane (chronic sinusitis). I perform quite a bit of complicated dental surgery and implant surgery, but there is no way in the world that I am going to start doing lateral window sinus lifts in my practice.....and I have assisted in dozens of these surgeries, in various settings. I understand that with the risks involved, and the complexity of the procedure, that this treatment is best left to be performed by people who have received extensive surgical training, and then also perform the procedure on a regular basis. It is not an "oh I do a couple of sinus lifts a year" thing. This procedure requires repetition to master. Yet here I am reading an email promoting a course where dentists can learn how to do a sinus lift in two days. This is unacceptable. It lowers the standards of training required to master complex treatments. Sinus lifts are not taught in dental school; they are too complicated. Many dentists have not done a residency of any sort so they have not been in operating rooms, and they have not really dealt with big surgical complications. Those who have will understand that the sinus lift is not a procedure for dentists who do not have extensive surgical training. Furthermore, the patient population in a general dental practice does not often require lateral window sinus lifts, so realistically, this treatment would be very infrequently performed in a general practice setting. I have a very dental implant driven practice, yet I only have a handful of patients a year that actually require a lateral window sinus lift (which I refer out); there is no way that I would have the demand for this procedure in my office to be able to be performing it on a regular basis to truly be competent at it. Especially after a two day course. And there is no way in the world that I would be able to perform a sinus lift better than a properly trained oral surgeon or periodontist. Even graduates from GPR (hospital residencies) programs may have only done a couple of them during training, if they got to at all. The reality of continuing education today is that companies are promoting complicated procedures to be completed in the general dental office. Business is business. It is in all of these companies best interests to get more dentists using their products. If more dentists are doing sinus lifts, more elevators are sold. The more Invisalign that is being done, the more trays they sell. When people place implants on an angle, like is required for the "all on four" technique, we have to buy an extra thousand dollars in parts to correct this angle.....instead of maybe placing the implants properly. And anyone who has taken the "pin hole" course knows that tuition is insane and the instruments cost a fortune. Business is business. This is not a new thing. Continuing dental education has always been product promotion driven. But things are getting way too complicated; it is no longer about what composite to use for molar fillings, or what core material makes the best foundation. The realm of general dentistry is getting expanded to include treatments that are very advanced. But do you want your dentist performing complex treatments on you because they took a course and bought a bunch of instruments, instead of referring to someone with more formal training? Complex surgery, orthodontics, dental implants, and even complex endodontics.....these are hard clinical skills to acquire, and are best taught in a residency. Yes, weekend courses and even multiple session programs are available for general dentists, but nothing replaces specialty training. Many general dentists are signing up for these complex courses. Many have completed some sort or residency, or have taken extensive continuing education. But some haven't, so they may not recognize the true complexity of the procedures (and products) being promoted. If a dental rep comes along promoting a course, telling the dentist "oh yea, come check it out, you will see it is easy to do and it will be a great service to offer your patients".......and the dentist has not completed a residency or very much CE, well they may just not have had the exposure to complex dentistry to really understand how challenging things are. And then there is the whole demand thing, are the dental needs of the patient population in a general dental office complicated enough so that the dentist is performing complex treatments with the frequency required to truly be comfortable and competent in advanced treatments such as sinus lifts? Dental specialists have 2-3 years of training on these complex procedures, in a setting that is not driven by companies.....well at least the rules are stricter in university and hospital settings for companies to come and promote their products. This is a much more unbiased approach to learning complex dentistry than taking a course put on by a company who's goal is to push products and augment market penetration. Furthermore, specialists design their offices to be able to regularly provide complex dentistry, they spend their days dealing with advanced treatments and managing complications, and have a dental team well versed in specialty care. Repetition is key to mastering any skill. If you have been recommended a complex treatment such as advanced dental surgery, orthodontics (including Invisalign), dental implants, or even complex root canals, consider having a consultation with a dental specialist. Thanks for reading! drdave@alfaropros.com #continuingeducation #sinuslifts

Pretty much at least once a week I have someone present on an emergency basis with concerns about severe tooth pain, a broken tooth, or some sort of swelling. Unfortunately, in many cases these symptoms are the result of a tooth that is necrotic (dead pulp), or well on its way to it. To save a tooth like this, a "root canal" is often required. Now this is a treatment that every dentist had to learn in order to graduate dental school, but some of us refer to specialists. I refer all of my root canals. It often takes some convincing, but in the end, my patients always understand why I do. Let us talk about referring out "root canals". Why would someone need a "root canal"? There are various components to the tooth. The outside of the tooth is enamel (or cementum at the root), which covers the dentin, which then surrounds the inside of the tooth, which is called the pulp. The nerves and blood vessels that feed the tooth enter the pulp via the tips of the roots, where they travel to the pulp chamber via the root canal system. When a tooth is injured by tooth decay, trauma, or excessive heat, cold or chemical attack, the cells inside the pulp die, including the immune cells that are constantly fighting off bacteria. Once dead or dying, the tooth can no longer defend itself, and the bacteria make themselves a nice little home inside the pulp chamber. They live there quietly until the toxins they make work their way down the root system and out of the tip of the roots, where they irritate the bone and cause a localized inflammatory/immune response. This is when people usually show up at the office, because that type of pain and pressure is often unbearable. At this point, a "root canal" is needed. To complete a root canal, the dentist must cut a hole into the top of the tooth in order to access the pulp chamber. Once the pulp chamber is cleaned up, the dentist must find the beginnings of the root canal systems in order to be able to disinfect them. After the root canal system is cleaned and disinfected, it is filled with a rubber based material. The coronal portion is then restored, often with a core and crown. If you learned how to do root canal fillings, why would you refer? Root canal filled teeth are notorious for breaking, and once a tooth is broken it often needs to be removed. Different dentists will tell you different reasons for why root canal treated teeth are prone to breakage: "the tooth dries up and becomes brittle" "the patient can't feel the tooth so they bite harder" "the root canal filling process puts pressure on the roots" All of these are possible explanations, but what is a more accepted reason is that a tooth requiring a root canal filling is often very damaged in the first place. The more that you remove material from a tooth, the weaker it is, and the more likely that it will break. Conservation of tooth structure is therefore paramount in every procedure we do. And this is why I refer. It is tricky to find the openings to the root canal systems, so often a big hole is made in the top of the tooth in order to see things, and to get the instruments in. Many dentists therefore perform root canal fillings with the help of magnification, thanks to "loupes". But there is a better option: microscopes. The use of microscopes has completely revolutionized root canal therapy because it allows the dentist to be as conservative as possible when trying to find the access points to the root canal systems. It is no longer necessary to make a big hole in the tooth for a root canal filling. Learning to work with microscopes, however, is not an easy task, and takes years of training to get comfortable with. Dental schools are implementing microscopes into their programs, but realistically the students are just learning how to drill with direct vision, and how to work in inverse with hand mirrors and dental loupes; throwing in a microscope is another challenge that is difficult to master in the short time that dental school really is. Endodontists are dental specialists who spend two to three years, and thousands of hours of clinical time, training how to use microscopes for their craft, all while tackling complex cases. Yes, a general dentist can work with a microscope too, but realistically it would take years, if not over a decade, to accumulate the amount training that endodontists spend working with microscopes during their residencies. Then throw in the fact that they spend all day every day treating root canals, and have customized their offices to allow themselves to provide the best care they can, there is no question in my mind that when my patient shows up with a throbbing molar, that they are getting booked with the first available endodontist. And my patients often complain about the referral. Why can't you do it? But it is so expensive! My insurance only covers a small portion! Can't we just pull it? Can I so somewhere that they do everything? No. Go to the specialist. Please. And eventually they do. I always follow up with my patients after their treatments, and review the report that I get from the endodontist with them. I show them the photos (like the ones below) so they understand why I sent them to a specialist. More often than not, they are that happy I did.....well, with a little grumbling about the price....but quality work does not come cheap. It is hard to understand what conservative endodontics is until you see it. Let me explain on a couple of pictures: Here you see that the entrances to the canals are not very visible, so there has been a large hole made in the top of the tooth. This tooth has been significantly weakened due to this procedure. Compare the picture above to this one below. A tiny hole has been made to access the canals. This would be virtually impossible to do without a microscope. (Courtesy: Dr. Ellen Park) Microscopes also allow for the completion of treatments in a novel manner. The usual "access" for a canine is a large hole in the back of the tooth. This case was completed via a tiny access on the tip of the tooth, significantly conserving tooth structure. (Courtesy: Dr. Mark Parhar) Here we can clearly compare a root canal access that was completed without a microscope, to one that was completed under a microscope. These are supporting teeth for a bridge; the access on the right is much more conservative and can improve the chances of the bridge remaining in place. (Courtesy: Dr. Joel Fransen) After looking through these cases I hope you can understand the role that technology plays in the quality of dental care that can be provided. If you need a root canal filling, ask if it will be completed under a microscope. If not, get a referral! Doesn't your oral health deserve the attention of a specialist? Thanks for reading! Dr. Dave drdave@alfaropros.com #RootCanals #Microscopes

I have a bunch of tree hugging vegan and vegetarian friends that are always posting pictures of cute cows and pigs suffering horrible deaths, and referring to vegetarian alternatives to animal proteins, trying to make us meat eaters feel guilty for being human. Well, it doesn't phase me. I eat cute animals; the younger and happier, the better. "But haven't you watched Cowspiracy? There are so many better options for protein!" Are there? Let us talk veggie protein again....... If you have watched Cowspiracy, or have followed any sort of veggie nutrition news, you will have heard of this upstart company that has created the saviour to the world's protein problem with their innovative "100% plant protein" burgers and faux meat products that are engineered to taste and feel like real meat. Check them here: http://beyondmeat.com/products They are the self proclaimed future of protein! They have created so much noise that they have attracted some big name investors and athlete reps...... But have you looked at what is in there????? If it is plant based, it is good for you, right? Check out their gorgeous website. 100% plant protein. Oooh that's good. Sexy ripped athletes. Hmmm I want to be skinny. Gorgeous looking faux meat patties. OMG looks like a real burger! So convincing. And it is plant based??? This must be good for you! All marketing. Marketing! Marketing! Marketing! They are totally riding the 100% plant based wave. I have news for all y'all hippies who think that "plant based" is synonymous with "natural": YOU ARE BEING FOOLED. Humans have been synthesizing things from plants for centuries. We have plant based plastics and rubbers. We have plant based solvents and detergents. We have plant based toxins. We have plant based "chemicals"....... everything we eat is a chemical. This burger is a synthetic product, no matter if you call it plant based. The ingredients are chemically treated in order for them to exist the way they do. Are synthetic things bad for you? Well, not necessarily, but wouldn't you rather eat something that exists naturally? I am very content knowing that my delicious ribeye steak is 100% beef, from a happy cute cow that spent its years hormone and antibiotic free, roaming an unpolluted range, eating pesticide free grasses and plants, and then getting fatted up on healthy grains just before being delicately butchered and aged to perfection. Yum. 100% Natural. So what is in that synthetic burger anyways? Let's look at those ingredients: http://beyondmeat.com/products/view/the-beast-burger The first ingredient is water. That's fine. Water is good for you! The second is pea protein isolate. What in the world does that mean? Like any vegetable, peas have a very low concentration of protein. Check out the nutritional data here: PEAS Peas are only about 5.5% protein by weight. But somehow we are going to use them for protein? In order to make an "isolate", the rest of the 94.5% needs to be removed. That entails roasting the peas, grinding them, and then washing them with a series of acids, bases and other solvents. The goal is to end up with a concentrate of amino acids, but realistically we end up with the proteins, and some other stuff. In that original 94.5% that is not protein, lie substances such as sugars and flavour compounds that end up getting concentrated too. Some of these chemicals can cause flatulence, allergy and gastric upset, or can affect the flavour, colour, or texture of the final product. To get the pea protein isolate just right is therefore a chemistry challenge (and usually a patented process). Pretty natural, right? But in the end, pea protein isolate appears to be relatively well tolerated by the human digestive system, to the point that it is even approved for baby formula. Is it as natural as my cute cow? NO. The third ingredient is a blend of fats. In fact, over half of the calories in this product come from fat. That is not very balanced. Yes, the fats are naturally sourced, and are from non-animal sources, but canola oil and palm oil are not without their own controversies. If I ate a burger that had 50% of its calories from fat, it would be very, very delicious. Probably moreso than this veggie patty (sadly they are not yet available in Canada). I'll just stop at the fourth ingredient: methylcellulose. Hey hippies.....do you know what this stuff is? Where it comes from? How it is made? Tree pulp. You know........ what we make toilet paper with? Methylcellulose, and other cellulose derivatives, are chemically created from the pulp of trees in a process that involves washing the mash with caustic bases and other solvents in order to draw out the natural fibre. The end result is a product that is pretty neat. It is a substance that gels when it is heated and liquefies when it cools, and it is colourless, flavourless and is virtually undigestible, making it a great additive to foods in order to alter the texture and cooking properties of the product. It is such a great synthetic chemical that it is used in various other capacities, including wallpaper glue, shampoos and hair products, insulation tiles, and my personal favourite fun fact: cellulose is one of the main ingredients in KY JELLY. MMMM.....don't you love having lubricant in your veggie patties? Yummm. I could go on and on about the rest of the ingredients, but you get the point. So yes, this veggie burger is derived from plants, but do you still consider it to be a "natural" product when all of the ingredients require so much refining? You may as well make a toilet paper burrito filled with some peas and margarine, and add splash of personal glide gel to taste. Heat and serve and call it a day. But it's vegan and 100% plant based! And it is going to save the woooooorld. That cow is looking mighty tasty to me. What about said cow? If you are REALLY boring and go for extra lean ground beef, a quarter pound patty would give you the same amount of protein as the aforementioned veggie burger, but with over 40% fewer calories, 85% less sodium, and over 60% less fat, with only 1 gram more of saturated fat, but yes, more cholesterol and no dietary fibre. Oh, and it truly is 100% natural. Now don't get me wrong, I love animals. They are cute. I feel sad when I watch the Sarah MacLachlan commercial. I get it. I definitely understand the environmental impacts of cattle farming, and we can talk about what I do at my office everyday to curb my carbon footprint another time. But I am a hungry human, and veggie protein just does not cut it. I am made of meat. Meat is made of meat. I eat the meat and my body is happy. If I eat protein powder, my digestive tract does not appreciate it. It is a no-brainer for me. Every former vegetarian I know has told me that they noticed a huge improvement in how they felt when they re-introduced healthy portions of healthy animal proteins to their diets. Hi fives to all of those rejoining the dark side!!!!! Once we humans get the hang of treating other humans with the respect and dignity that some people give animals, maybe I will consider eating vegetarian. Haha kidding. I love steak. Thanks for reading! Dr. Dave drdave@alfaropros.com #Nutrition #Vegetarians #hippies #beef

Wow! It has been a mega long time since I have sat down and blogged away! I have to blame the beautiful weather that we have been having. This is the first cloudy weekend we have had in weeks and when it is sunny, the last thing I want to be doing is reading and writing nerdy dental stuff. But it is a cloudy Saturday so I may as well write something. Last week a patient of mine presented to the office for his cleaning appointment and finally after various visits of my informing him of some problems, he finally agreed to have fillings replaced that were beginning to have decay around them. Of course, his questions were: 1) Why do they need replacement? 2) Why weren't they done properly? (ie why did the fillings fail) These are questions that always come up when I see work that needs replacement, so I figured that it would be a good topic to write about. Let us talk about the replacement of dental fillings. Why would someone require a dental filling in the first place? There are pretty obvious reasons why someone may require a dental filling, such as a chipped or worn down tooth, so patients don't really question why the treatment would be recommended in those scenarios. Dental caries, however, is a process that patients may not even be aware is happening, so they often question me if or why a filling is required. And dental caries truly is a process. The mouth is full of bacteria; some good, some bad. And people have different strains of the good and the bad, making their mouths more or less susceptible to oral diseases than others. Then there are personal habits, such as brushing, flossing and diet, which are also highly variable, and often neglected. It amazes me when so many people complain about how expensive dental care is, that so many still do not brush their teeth and floss properly, and they continue to drink sugary drinks and foods. Getting people to change habits is the hardest part of my profession, and I take on extreme challenges of manual dexterity on a daily basis. People get free floss, free toothpaste, free brushes, and free advice (there is actually a billable code for oral hygiene instructions that I do not often use), so it is really a matter of time and effort......a people still show up with inflamed gums and teeth covered in plaque. Not my fault by that point. When you consume sugary foods and beverages, the bacteria eat it up and make acid as a waste product. The acid eats away at the minerals of the teeth, weakening them. Furthermore, when the bacteria gobble up sugar, they also use the byproducts to make themselves a nice little environment to live in as one big happy family (plaque and calculus). If not removed with a daily frequency, the amount of bacteria multiply rapidly and they become very effective acid forming colonies, causing tooth demineralization. This demineralization, when it gets severe enough, can be visible on an x-ray, and has some clinical signs as well. If sugar intake is minimal and infrequent, the teeth are able to take up minerals from the saliva and fix themselves up. But, like is too often the case, people do not brush and floss well enough, and they keep poor diets, and the bacteria win the battle, and the teeth begin to decay. Once the demineralization is severe enough, a hole can form on the surface of the tooth: a cavity. There was a time, and I am sure that there are some aggressive dentists still practicing this way, where any evidence of dental caries was treated immediately with a large amalgam filling. "Extension for prevention" This antiquated approach really caused more destruction to tooth structure than protection, but it was due to a limitation of the restorative materials that were available at the time (dental amalgam). Today, it is pretty much consensus that a tooth only requires a filling if there is a cavity, meaning we can try to remineralize the teeth in mild cases of tooth decay. In my office, I prefer to not have to drill a hole, unless their is clear evidence that there already is one, or if there is evidence of progression of the decay, or if the person is at high caries risk. We have multiple non-surgical approaches to the management of dental caries: behaviour management, FLOURIDE, and remineralization agents. I always give these a try first. And if I have to drill a hole, I am as conservative as possible, and select my materials based on the clinical scenario. Why would a filling need replacement? Again, there are obvious reasons as to why a filling would require replacement, such as broken fillings, loose fillings, or loss of aesthetics (primarily for front teeth). Dental caries, however, is the most common reason that dental fillings need replacement. And this is where the blame game begins. The first thing that some patients say when I tell them that a filling needs replacement due to tooth decay is, "well, why wasn't it done properly in the first place?" Ok, yes there are times when a filling is just not placed right. Dentistry is difficult and sometimes things just don't work out ideally. And if it doesn't...it should be redone. But, dental caries is a process. Placing a filling does not stop this process, it just patches up the results of tooth decay. Dental fillings do not cure dental caries; they treat tooth decay. In order to fight dental caries, more than just the mechanical filling of the cavity is required. Reductions in sugar intake, improvements in oral hygiene, the incorporation of fluoride and remineralization agents, and frequent dental visits, are all recommended in order to truly combat dental caries, especially in someone with a history of tooth decay and dental fillings. For the gentleman who I recommended that we replace his fillings, once we removed the old composite, there was decay everywhere, causing him to ask the question of why things were not done properly in the first place. It is hard to explain to someone the dental caries process, and that a dental filling itself had not failed and was placed well in the first place, and that it was actually the tooth around the filling that was failing. Dental caries is strong enough to destroy perfectly intact dental enamel. No matter how good a dentist is, or how high quality of a material we use, there will always be a junction between the tooth and the filling, and this is a weak spot where tooth decay often attacks, just like grime sticking to the grout between bathroom tiles. If people are not brushing away plaque and bacteria, the acid attacks the junction between the tooth and the filling, and the filling remains fine, but the tooth begins to fail. Dental caries is a process. Isn't this just one big "racket"? Whenever there is an article online about dentistry, I love seeing all the anti-dentite trolls piping up about how it is just one big racket, and that dentists are all rich and taking advantage of patients. When we dentists tell our patients that a treatment that they paid a lot of money for will not last forever, I can see why people would get upset. It is an expensive endeavour patching up years of tooth decay, but we are fighting a disease process, which in the end is often the winner, so we cannot say that something will last forever. And there is such an unreasonable expectation for dental work to last forever. I mean, who still has an Iphone 3? Or a CRT television? Or has worn the same shoes everyday for ten years? But a filling needing replacement after a decade of neglect, extreme temperature changes, ridiculous bite forces, and exposure to acids.......that is unacceptable! And it usually isn't even the filling, but the tooth around the filling, that fails first. Yes, there is a segment of my profession that is profit driven, and there is some pretty shady stuff happening right now in Vancouver (and probably across North America), but I know and work with many honest dentists who are truly concerned with the oral health of their patients. If you think dentistry is a racket, you are going to the wrong place. In my practice, I try to be as conservative as possible. The reality is that there is so much dental work that is needed out there, and as a specialist I spend so much of my time providing very complex dental treatments, that there is no reason for me to be aggressive and to drill holes for something that might be tooth decay, or to recommend "cosmetic dentistry" to someone with pretty nice, natural looking teeth. I am in the business of helping people keep their teeth healthy, for longer, especially having the experience of treating extremely damaged dentitions on a daily basis. It may be hippy of me, and I definitely could pay off my student loans faster if I was pushing veneers and botox on everyone, but I am happy having someone come in for a check up and a cleaning and seeing them off with nothing further until their next cleaning. There is nothing more cosmetic than a healthy, natural smile. Thanks for reading!!! Dr. Dave drdave@alfaropros.com #ToothDecay #Fillings #Ethics

It astonishes me how for some reason one article or video can catch on and spread like wildfire to multiple traditional media and social media outlets in just a few hours. Have you guys read this one about sprint training? http://www.huffingtonpost.com/entry/high-intensity-workouts-hiit-bad-for-beginners_us_56f2eceae4b0c3ef5217ae60 A couple of weeks ago, this topic was all over various outlets, with the conclusion that HIIT can result in damaged mitochondria and decreased capacity to fight free radicals. There are hundreds and hundreds of research papers on HIIT and somehow, this one magically becomes the golden child and goes viral? Let us talk about HIIT. What is High Intensity Interval Training? High Intensity Interval Training training (HIIT) is exactly what the name says it is; an exercise modality that utilizes short bouts of high intensity exercise alternated with periods of low intensity exercise. There are various techniques and methods (eg Tabata, Fartlek) that have been shown to improve performance, even in highly trained athletes. The benefit of this type of training is that you are pushing your body to create energy (ATP) using systems that do not rely on oxygen. Aerobic respiration (oxygen consuming) can only provide enough ATP for lower intensity exercises, so we need these backup systems to kick in when the intensity ramps up. These anaerobic systems, however, create byproducts which are often considered to be "toxic" (eg lactate). But.....the body adapts. There is evidence that the body has many positive short term and long term adaptive responses to the presence of anaerobic byproducts: -blood flow increases to areas of high concentrations of toxic byproducts (reactive hyperemia) -the formation of new capillaries is induced, allowing for increased blood delivery long term -enzyme concentration and function improves for both the aerobic and anaerobic systems -some people even believe that the quality of muscle fibres change according to the type of stress they are under The presence of these "toxic" byproducts creates a positive adaptation. Does High Intensity Interval Training Work? Simply: Yes. -HIIT decreases blood pressure and improves oxygen uptake in obese children, better than other exercise programs -HIIT improves measures of diabetes (body weight, HbA1c) in comparison to continuous training -HIIT improves vascular function -HIIT improves cardiovascular function in people with heart disease It is not to say, however, that continuous intensity exercise programs are not necessary. Continuous intensity programs have been shown to have better long term benefits in weight control and resting heart rate than HIIT. What about that research paper that said HIIT is bad for you? I would be surprised if any of the journalists who reported on this article actually sat down and read the paper. Give it a read: http://www.fasebj.org/content/30/1/417 To summarize the article quickly, 12 "untrained" Swedish young men were put through high interval training programs, performed on a leg cycle and an arm cycle machine. After the training periods, various tests were completed, including biopsies from the arms and the legs. The tissues were then broken down and various tests performed. The researchers were interested in mitochondrial function and enzyme levels after HIIT training. For those who do not remember, the mitochondria are the "energy cells" and are where various processes occur that create ATP. Now, I have a kinesiology degree from a really tough program where we had to learn very advanced human physiology, anatomy and biochemistry, but to really understand this paper you need a doctorate. To truly critique the isolation techniques and assays, you have to know lab research. I sure don't. But I can read the article and look at the methodology and question things. The first thing that stands out is that there was only one group being studied (no control). Would the findings be different on trained subjects? Or women? Or older men? Or non-Swedes? Then, there is the way they applied the interventions. There were two exercises that were performed, one on a bicycle and then another on a machine that you pedal with your arms. This was to be able to compare two different muscle groups. Who in the world rides their bike with their arms? Most people run, walk and ride bikes, so they have some sort of familiarity with the leg test, but peddling with arms? I have always questioned the validity of comparing the arm cycle test to the leg cycle test. And finally, the conclusions: there were two totally different results when the arms were compared to the legs. The legs actually showed what I consider to be positive adaptations: there was in increase in mitochondrial density and the mitochondria were functioning at lower rates. That means the body responded by increasing the amount of power cells, and decreasing the amount of power drawn from each one, meaning....that when the intensity ramps up again, there are more cells with more reserve to draw from. That is good, right? But the arms told a slightly different story. There were reductions in an enzyme (aconitase) which is believed to play a role in how well the mitochondria respond to oxidative stresses. This reduction, however, was not found in the legs muscles, because there was an increase in mitochondrial density. Why would there be a difference between the arms and the legs? Well, the authors did not have a concrete explanation for this, but did mention that perhaps the legs were used to that kind of training and the arms weren't, so the two muscles actually experienced different oxidative stresses during the study. Kind of a big variable don't you think? So how did this article gain so much traction? I blame bias. The authors demonstrate bias right from their title. Their paper found that, "HIT increases work capacity, mitochondrial density, and oxidative enzyme activity, without change in myosin heavy chain composition." Basically the subjects could work out harder, had more energy cells, and were able to burn oxygen better, all without changes in the actual muscles. The study also only showed negative results in the triceps, and there is question whether the intensity levels were truly the same between the arms and legs......yet the title was: "High-intensity sprint training inhibits mitochondrial respiration through aconitase inactivation" Catchy! But..... deceptive....because that statement only represents half of their results, and the rest of their data had findings that can be interpreted as positive adaptations. (My own bias showing through) But this is how researchers can draw attention to their papers, and why people catch on to specific articles but not others; the persuasion of a catchy title and a biased abstract. The huffington post article even made the leap between free radicals and cancer.....so HIIT will cause cancer??? Comon!!! To really understand the article, you have to read the whole thing. On similar note, check out this great Ted Talk on publication bias. What can we conclude about HIIT? If you are considering starting a HIIT program, get proper training. Go to a gym that has actual kinesiologists as training staff. Anyone can do a 6 week course online and call themselves a trainer, but a kin degree is a totally different thing. If you have any health concerns or have answered yes to any of the questions on the PAR-Q (if your trainer hasn't asked you to fill one out, ask yourself why), talk to your physician before starting any program. And work your way up! It is unhealthy and unsustainable to go from zero to hero overnight. Do not just go from couch sitting to crossfit or from sedentary to sprinting. It is a sure way to get injured and to hate what you are doing. Baby steps! Thanks for reading, Dr. Dave drdave@alfaropros.com B.Sc (Kinesiology) #DietandExercise #HIIT #Training #Deception

Ok I know that I have been spewing out a quick succession of nerdy dental posts over the last couple weeks, so I apologize if it is getting a little monotonous. But things just keep happening that I need to write about immediately or the moment is lost. One of the reasons that I write this blog is to help educate people about the role that dental specialists play in the provision of dental care, especially for my own specialty, prosthodontics. People really do not know what a prosthdontist is or what we do. As I mentioned, I recently joined a Facebook forum for dental specialists, and I decided to take a chance and share my blog with the members of the group. I figured that I was writing about topics that the members might relate to, and ones that they may want to share with friends, colleagues and patients. Again, to my surprise, a specialist in the group made a comment to me that made me think that not even people in my community know exactly what my role is as a prosthodontist. If you have been reading along, you have seen that I write about all sorts of topics in dentistry and health care, not just limited to my own specialization. An orthodontist in the group mentioned to me that he was surprised that I would be writing about orthodontics, and that it would be like he writing about zirconia, kind of as if I was stepping on his turf. Hey man! We are teammates playing on the same side. As a prosthodontist, I NEED to know what an orthodontist does. It is a cheesy sports cliche, but when patients present to my office and require the help of other specialists, someone has to be the "quarterback" of that plan, and it is often me, the prosthodontist, who takes on that role. Let us talk about interdisciplinary dental treatment. What does interdisciplinary dental care mean? When someone presents to my office for the first time, the first step of the process is to perform a comprehensive examination (and history) and to put together some treatment options for them. Many patients will have a diverse problem list, with findings that could include tooth decay, gum disease, necrotic teeth (dead teeth), missing teeth and crooked teeth or misaligned bites, in addition to many other things. A patient with these problems will be presented with a range of treatment options, with the preferrable route being the comprehensive resolution of the concerns in a coordinated manner. Complex treatment plans such as these could therefore require multiple advanced treatments such as gum surgeries, root canal fillings, dental implants or orthodontics. Now this could be done in one office by one person, and increasingly so, this is what is happening in Vancouver. But it is not necessarily the best approach, and it is definitely not the approach I take; I refer. Of course I learned how to do all aspects of dentistry during dental school, but this was at a very superficial, entry level. In dental school we focused on cleanings, fillings and simple prosthodontics, endodontics and minor dental surgery. We do not get advanced training in complex care in dental school. So I refer. I know that an orthodontist is going to give my patient a better result than I can if my patient needs braces. I know that if I send my patient to an endodontist, that root canal filling will be completed quickly and under a microscope so there will be a miniscule access opening and maximum conservation of tooth structure. I don't do gum grafts; that takes years of training to really get down. Yes, it costs more money up front, and my patients may have to go to various other specialists to get their care completed, but, in the end, I can be comfortable that I did everything I can in order to get the patient healthy, with the highest predictability possible. I do not want to be fumbling around with Invisalign in my office, or doing a root canal without a microscope, or "laying a patch" on a botched gum graft. That is not specialized dentistry. I refer. I have a network of specialists and general dentists that I work with as a team: interdisciplinary dental care. What is the prosthodontist's role in interdisciplinary care? A complex treatment plan that involves multiple specialists needs to be coordinated by someone, and that person is often me, the prosthodontist. When multiple treatments are required and they are to be performed by multiple doctors, they need to be planned and sequenced in a manner that is logical and healthy for the patient, and since the prosthodontist is the one who will be finalizing the treatment, it makes sense for us to be the ones driving the treatment plan. So as a prosthodontist, I do not just need to know the finer details of my specialization, I need to know about the treatments that my colleagues provide. It is imperative that I understand the predictability of orthodontic treatments, including invisalign. I need to know the limitations, complications and challenges that periodontists face when performing soft tissue grafting procedures. I need to know whether or not a patient needs a hip graft and a referral to an oral surgeon with hospital privileges. You get my point. A major component of my specialty training was geared towards just this, being the quarterback of comprehensive treatment plans. We had guest lecturures from all specialities in my prosthodontic classes, we worked on clinical cases in coordination with other residents, and we had a weekly "interdisciplinary treatment planning" course where all of the speciality students were involved and had to present cases for discussion. This seminar was a new concept to the graduate dentistry program and man did it get off to a tough start. Egos and pride got in the way of teamwork. But slowly, it became a very productive, imperative part of the program because we really got to see how the other specialists evaluate and plan their cases. This is essential to know as a prosthodontist. Of course I did not get to learn the biomechanics of orthodontics, or the difference between different file systems for endo, but we focused on the diagnosis of patients, and the predictability and complications related to treatments. Prosthodontics is not just about zirconia and emax and vertical dimension. Prosthodontists are specialists who have to understand each and every other specialization. So yes, I feel comfortable writing an entry level article on the pros and cons of clear aligners. Every prosthodontist should. Can't my general dentist do everything? Of course they can. But should they? Complex dentistry is difficult and being good at all aspects of dentistry is very challenging at takes years and years of continuing education. Dental specialists have the advanced training and the experience required to take on more complicated scenarios, and believe me, treatments such as orthodontics, dental implants or endodontics can be very challenging (amongst other things as well). We are used to seeing specialists in so many other fields, but somehow dentistry is bucking the trend and dentists are deciding to keep everything in house. Lawyers, accountants, physicians, tradespeople, chefs, the beauty field; all of these have specialties that you go to. You don't see a divorce lawyer for a real estate purchase, you don't get your nails done by your hairstylist who sometimes does nails, and you certainly don't ask your physician for a rhinoplasty. So why would you expect your dentist to be an expert in braces, root canals, extractions, grafting, implants, crowns, bridges, veneers, dentures?.......the list goes on and on. Dentistry is a broad field and is technically challenging. When my patients require complex dentistry, I rely on interdisciplinary care. By sending my patients to other specialists, I know that they will be getting the best care available. Doesn't your smile deserve a specialist's attention? Thanks for reading. Dr. Dave drdave@alfaropros.com #prosthodontics #treatmentplanning #SpecialtyDentistry

So I was at the dental conference last weekend, and just like I usually do, I skipped most of the self and product promoting podium talks and wandered the exhibit floor looking for stuff for the office. I needed a LASEEEERRRRRR. I have been using soft tissue lasers forever, but I did not have one at the new practice, so it was on the shopping list. If you guys haven't been to a tradeshow like this, it really can be a nightmare. There were over 12 000 people and hundreds of exhibitors. I try to just walk in the middle of the aisles and avoid eye contact. The attention is nice, but I kind of feel like the woman in that "American Girl in Italy" photograph. I finally see the laser that I was looking for and I make my approach; total slimeball sales rep, but...I wanted this laser so I played along with his banter. He is going over the features of this laser and he tells me, "oh, and I will throw in the 4-hour online training for free. You can call yourself a Certified Laser Dentist!" I say, "excuse me? There is no such thing as a certified laser dentist." And he was kind of shocked. I reviewed with him that in BC we can only be "certified" as general dentists or specialists, which was nerdy and rude of me, but morally necessary. There is no such thing as a laser dentist. Let us talk about advertising once again. I am sure that you are starting to see a trend in the topics I write about, but it is because I am pretty sour at the way that advertising has taken over my profession. Shady advertising is confusing to the public. My brother has a PhD and is one of the smartest people I know. He loves gadgets. A couple of years ago he told me that he had been going to a "laser dentist" and that the doctor also makes the crowns in his office. I say, "excuse me?" No!No!No!No! Brother!!!! I look up the doc, and he is advertising himself as a "laser dentist" that does "pain free" and "needle free" dentistry. That is unethical and against the college regulations...... Randomly, I end up meeting the doc at a later date and we start chatting and he finds out that I am a prosthodontist, and he tells me, "oh yea, I never refer to you guys. I have done a couple of sinus lifts in a study club and I place a couple of implants a year. I do everything Cerec. My lab bills are way lower than yours." This kind of attitude kills me. A sinus lift is a crazy difficult procedure and is not something that you do from time to time in a study club. Dental implants are similar; you need proper training and routine practice and exposure to the long term maintenance of the prosthetics in order to truly understand how to manage them. Do not even get me started on in-house milling. But this is what is going on out there. The dental conference even had live-surgery sinus lifts and immediate implant placement and restoration, complete with a song and dance. No joke. They were dancing to disco music!!!! Why????? Totally unprofessional. Do you want your general dentist to watch a surgery on stage, performed by someone who has done hundreds if not thousands of them, who is up there because an implant company paid a large sum of money, and think.....hey! I can do that in my office too!!!? No way. This is just straight up wrong, but people are either unaware of the complications that can happen with advanced dentistry, are blinded by these aggressive marketing schemes, are convinced that referring patients is costing them money, or want to learn everything to become a "jack of all trades"..... so they take on challenging cases in their practices. And the public doesn't know. How do you know if you are seeing someone who has received adequate training in a procedure? Let me tell you, in dental school, students are just learning how to use handpieces, are just learning to tell dentin apart from enamel, and definitely do not get adequate training in dental implants or orthodontics to truly be able to do it upon graduating. Dentistry has grown so much that there is just way too much to learn and not enough time; some programs really only have about 18 months of clinical training. That time flies by. The reality is that dental students graduate with the bare minimum skillset required to go out there and do basic dentistry, without maleficence. Some recent graduates are humble about it and understand that dentistry is actually quite difficult and slowly work up to challenging cases. Others come out overconfident and start doing complex endodontics, oral surgery, invisalign; everything. That is... until they own their own practices and start seeing how much remaking and redoing and retrying stuff costs, and what it does to the confidence that patients have in them. Fumbling around while attempting something new or difficult in order to keep the treatments "in-house" is not a good business model. A dental practice is not a place to practise. How do dentists gain experience in advanced dentistry? Study clubs. Courses. Lectures. Weekend programs. Cruises. Or just trying and learning as they go. Or....they enter a university level specialist training program and really learn the details of advanced dentistry, including the history and current research, and then focus their practices on a subset of all of the clinical skills that are required of our practice. Specialized dental care. So don't be fooled by gadgets and gimmicks; general dentists are general dentists; specialists are specialists. Being a laser dentist is not a real thing. Doing invisalign or six month smiles does not make you an orthodontist. If there is no microscope in the office, they are not doing endodontics right. There is no such thing as a dental implantologist. Do not be fooled by advertising techniques or posters with pretty smiling faces! If you need dentistry beyond basic surgery, fillings, crowns and bridges, consider a consultation with a dental specialist. Every good dentist should have a network of specialists that they collaborate with and will gladly refer you, even if it is just for a second opinion. I frequently get referrals from doctors who want me to take a second look, and then we work through the case together. The patient gets the best care that both of us can provide! Doesn't your smile deserve a specialists attention? Thanks for reading. Dr. Dave drdave@alfaropros.com #Lasers #Falseadvertising #BusinessofDentistry #SpecialtyDentistry

So I am going to rant here...... I recently joined a dental specialist forum on Facebook. It is a group that shares articles and discusses topics surrounding our lives and careers as dental specialists. One of the roles of this group is to connect people as well. A doctor posted to the group a recent request for a recommendation for a prosthodontist in their area because they had a patient with severe tooth decay that was challenging to manage. One of the first replies was, "I love prosthodontists, but.....you need to manage the caries......and if that doesn't work refer them to the prosthodontist for implants." This was shocking to me. Prosthodontics is an obscure dental specialty; there are only 37 of us registered in BC and a half dozen of those are near retirement or working solely in academic or hospital settings. Dental students are not picking it as a specialization. Out of my graduating class at Columbia, where we had a dozen people go into orthodontics, a dozen into OMFS, and another dozen into pediatric dentistry, we only had 3 enter prosthodontic programs right away, and one more student a year later. My accountant has even told me that I am in a dying specialty! Not many people know what a prosthodontist is, or what we do. But I figured of all people to know the role of the prosthodontist, it would be another dental specialist. How could this person assume that a prosthodontist would not be able to manage the patient's caries? Let us talk disease management. I clean teeth. Me. Myself. Not my hygienist. I do not refer to a periodontist for cleanings..... who by the way would likely not be doing the cleanings themselves. I sit down and scale and debride the teeth of every single patient that is in my office for routine dental care. And if someone is directed to my office from another clinic and there is plaque or calculus present on his or her teeth, the first thing I do is chat with the referring doctor and let he or she know that the patient is due for a hygiene appointment, and that if they want, I can take care of it myself. Me. Not a hygienist. So this is why I am so angry that another specialist would assume that a prosthodontist would not be the right choice to help manage that patient's dental caries. Why do I clean teeth? People do not often end up in a prosthodontist's office because they have healthy clean mouths. They have tooth decay. They have gum disease. The have dead or dying teeth. They have broken dental work. The do not know how to manage their oral health properly; things are a mess. These are not static processes; they are a continuum of disease that need to be managed chronically. The first step in any prosthodontic care is therefore disease management. So that is what I do. I speak to every patient myself and ask them what their goals are, and what their habits are. Yes, I have forms that they fill out, but really, those are just legal requirements to me. I sit down and find out where someone is in their oral health patterns personally, in an interview, and then during a comprehensive exam. Then I clean their teeth. To me, providing someone with a dental cleaning is much more than just cleaning their teeth. I get to really complete the examination at this point. I get to know exactly how well each and every one of their fillings or crowns are fitting, I get to find out where they have problems cleaning, and I often catch periodontal pockets and dental caries that were not so visible in my first examination. I also get the chance to determine if the person requires more aggressive behavioural and/or chemotherapeutic interventions to get them on the path to good health. A cleaning is much more than a cleaning. Furthermore, it is the first step in the management of both periodontal disease and dental caries. Why would I pass this job on to someone else? Because my practice is too busy? Because I have been trained to provide very complex dental work? Because it is below my training level or pay grade? The reality is that it is not often cost effective for dentists to be performing extensive examinations and dental hygiene appointments at most offices, especially in Vancouver. We have crazy lease payments. We have massive staffing costs. We have hundreds and thousands of dollars of student loans to pay off. Fancy offices are the trend, and that equipment costs money. It would not be unreasonable for a practice to have hundreds if not thousands of dollars of overhead zipping by per hour. A dentist working in that environment would lose money if they sat down with someone for an hour to clean their teeth. It is simple economics. So I have insulated myself from that. I have one receptionist, and one assistant. That's it. I have a small office in the suburbs. I do not have a view of downtown, nor do I have unnecessary gadgets in the office. I dont own a car and I take the train to work. But I am lucky that as a specialist, I spend most of my time performing complex dental care. This allows me to sit down with each and every one of my patients and give them the time that that is required in order to make positive changes in their oral health, be it a simple cleaning, or dental implants. Yes, performing hygiene myself is not the most lucrative way for me to manage my practice, but it allows me to be efficient with my time while keeping staffing to a minimum. I see a couple of patients a day for complex prosthodontic care, and then am freed up to take care of my maintenance patients while my assistant sets up for the next surgery or cleans up for the day. I don't run around and every one gets my full attention. I don't need a second assistant and I do not need to be seeing multiple patients at a time. Although I could be..... I do sometimes wish that I had that fancy office with a gorgeous view and marble floors, or a $100K vehicle, but that is not me. I would not be able to sit down to chat with someone for an hour while I scale away plaque and calculus. And to me this is important. I have enough complex dental work to keep me busy and stressed out, and I have this work because people are not taking care of themselves. If I am not sitting down and helping them improve their health patterns, I am not being the best prosthodontist that I can be. So I hope that the gentleman who wrote that comment takes a moment to read this article and realizes that as a prosthodontist, the first thing I do is manage disease. Before any fancy aesthetic porcelain veneers, or dental implants or removable dentures. And if I succeed at managing disease, maybe my patients will need less of my speciality care, and if they do, hopefully it will be later on in life. One of the goals of my blog is to educate the public (and other dentists too, I guess) about speciality dentistry, and prosthodontics in particular. People do not know what we do, but little by little, I want people start recognizing that we should not be a last resort for people with failing dentitions, but are integral part of the spectrum of general dentistry referral services, and that patients should not be afraid to seek out care at our offices on their own. Doesn't your smile deserve a specialist's attention? Thanks for reading! Dr. Dave drdave@alfaropros.com #OralHygiene #dentalcaries #Periodontitis #practicemanagement

We give up too easily. Take a look at this radiograph: Now please pardon the quality, because it is from before the office was digital, but I am sure that you can clearly make out the extent of bone loss that has occured, particularly in the maxilla. Coupled with the pneumatization of the sinuses, if this patient presented to most offices with this extent of periodontal disease, there would likely be one treatment recommended: All-on-four. Every implant company is pushing some sort of four-implant, angled, fixed solution, and they are marketing them as an easy, convient option that solves problems quickly, and permanently. We know that it works. But does that mean that we should give up so easily? What if we tried to save these teeth? Would that be crazy? Yes, there is loss of bone support. Yes, there is class II mobility throughout the dentition. Yes, there are areas of periodontal pocketing. But, what if we did not just give up? Well, in this case, Dr. Ma did not give up. He put the patient through the classical periodontal management for someone with chronic periodontitis, by starting with four quadrants of debridement, re-evaluation, and then periodontal pocket reduction surgeries where indicated. Nothing fancy. Nothing expensive (relative to all-on-four). Nothing new. No grafting. Most importantly, he was able to implement a change in the patient's behaviour; brushing improved, flossing improved, diet improved, and 4-month maintenance appointments were abided by. It took a lot of motivation on the patient's behalf to try keep those teeth. Would you have told the patient to extract everything, or would you have taken the time to give it a shot at saving them? You know, until I starting seeing the outcomes of a succesful, traditional periodontal maintenance program, I was not a believer that people could actually change their habits. I would have said, "yank em all out". But if you can help people make positive changes, things can work out. This case is a perfect example of why we should not give up so easily. That first radiograph was taken over 15 years ago! And this was the patient a couple of years back (again before digital, sorry): And last week (ok I am not the best photographer)...... Minimal progression of periodontal disease. Yes, the lower jaw required some extractions, but the upper teeth have remained relatively stable. This patient made a life changing modification to their daily and professional hygiene routine that has allowed them to live another 17 years with what surely most people (including myself) would have deemed to be a failing dentition. Yes, the class II mobility remains and there are exposed roots and areas of mucogingival defects, but the periodontal condition is stable (3-4 mm pockets, crestal cortication on radiographic evalution, minimal BOP), and more importantly, the patient is happy that they have been able to keep their teeth for this long. Anyone who has worked with all-on-four, or hybrid prostheses in general, knows that, while they work, they are very far from being "successful" treatments. Maintenance is time consuming for both the patient and the dentist. Components are expensive. Lab costs are crazy expensive. Acrylic teeth break and fall off at an extremely high rate. Patients need to know this up front when they are dropping tens of thousands of dollars on a treatment. These treatments are not forever and they cost a lot of money to maintain! If you haven't worked with hybrids.....they are not as simple as the reps or podium doctors tell you. I have been in many a study club where people have tried this in their general dental practice and have ended up with a very expensive, time consuming mess, sometimes ending up in referral. Not a confidence booster for the patient! And do you really want to have a hunk of acrylic screwed in to someones mouth who has not been able to implement healthy home hygiene habits? I have seen some horrible, malodourous, hybrid dentures in my day, with very inflamed peri-implant soft tissues because people just do not take the time to clean these the way they have to be. We have to face the fact that patients lose teeth because of poor homecare, and screwing down acrylic and metal into a poorly maintained environment is not a good idea. Now that I have taken over a periodontal practice and have seen the positive effects that proper home care has on the "failing dentition", I will gladly sit down and scale and debride roots for someone, and help them get on the path to healthy oral habits. This is the first step in any prosthodontic treatment as anything I do in the face of plaque and calculus will surely fail in the future, no matter how smooth my margins are, how clean of an impression I make, or how well the labwork is fabricated. I guess that is why the reps have stopped coming by my office trying to get me on this bandwagon......it is not my treatment of choice and they know that it is my last resort. Thanks for reading! Dr. Dave drdave@alfaropros.com p.s. I am sure that those following along have noticed that I rarely post any patient photographs or radiographs. Please be assured that I discussed this with my patient and have gratefully received permission to use their photographs and radiographs for this educational purpose. Thanks again for letting me share your experience! #Periodontitis #allonfour #marketing

More and more adults are seeking orthodontic care nowadays, and one of the main driving forces in this trend is the emergence of various clear aligner systems, such as Invisalign. I am pretty sure that everyone reading this has heard of Invisalign and knows someone who has had it done and perhaps even considered it themselves. Of course, being a dentist, whenever I run into someone who has Invisalign on, they want to chat about it, and I often find myself having to bite my tongue. Clear aligner systems are valid orthodontic techniques, but they definitely have their limitations. Case selection is key to success. Unfortunately, I keep running into people who have clear aligners on, and without even completing an examination, I can tell that their malocclusions (misaligned bites) are way beyond what the indications of a clear aligner system are. And then I probe.....how long have you been in treatment? Over two years..... Are you happy with your smile? Yes, pretty much. How about your bite? mmmmm, well, it feels funny. And the kicker.....ok, well who is your orthodontist? My orthodontist? No, I did not see a specialist....... Let us talk about clear aligner systems. What are clear aligners? The concept of using clear plastic trays to move and hold teeth in position has been around for decades, but recent advances in computer design and computer manufacturing processes have caused a significant boom in this industry since the late 1990's. There are currently multiple clear aligner orthodontic systems on the market, with the most well known product being Invisalign. Generally, clear aligners work in this manner: 1. The dentist (or assistant usually) takes an impression of the teeth and submits the case to the company, along with photographs and radiographs. The impression can be made with the traditional impression pastes, or they can be taken with intraoral digital scanners. 2. The dentist then fills out an online "prescription" for the patient, where they indicate what teeth they want moved, and how. Most of the products have some sort of 3d modelling that you can show the patient to estimate what the final result will look like. 3. The company then makes a series of "trays", which the dentist is to deliver to the patient on a specific schedule. The dentist may have to make modifications to the teeth as treatment progresses, such as making teeth thinner or adding attachments that help control the forces. Normal treatment times range from 6 months for simpler cases, to upwards of 2 years for more complicated scenarios. What are the benefits of clear aligners? There are many advantages of clear aligner systems in comparison to traditional braces. 1. People like the option of a clear tray Patient acceptance is great, especially for adults. The trays are clear, and while not invisible, can be barely noticable at conversation distance. The ability to take them on and off for social settings and public speaking engagements is a huge advantage for adults and teens alike. 2. It is removable Being removable appliances, clear aligner systems have significant advantages in terms of home care. Patients can continue with fairly normal brushing and flossing habits, and research has shown that clear aligner systems result in much less gum inflammation and plaque buildup in comparison to traditional braces. Furthermore, as there are no brackets and wires everywhere, there are no dietary restrictions like in traditional appliances. 3. It is simpler for the dentist in comparison to traditional braces There are some advantages to the dentist as well, as appointment times tend to be shorter, less supplies are needed, there are less emergencies, and minimal training is required in comparison to what is necessary in order to properly learn how to provide traditional braces. What are the disadvantages to clear aligners? 1. Clear aligners alone have limited indications These clear tray systems are not meant for every type of "malocclusion". They are really best suited for minor cases of misalignment of the front teeth. 2. Advanced cases require a combination of clear aligners and traditional orthodontic techniques Advanced users have developed techniques that allow them to take on more challenging cases, but they often include the use of buttons and elastics to help move teeth. The reason for this is very obvious: the trays cover the biting surfaces of the teeth. Because the trays cover the teeth entirely, there is no way that the dentist can properly align the bite without using some sort of advanced technique. The tray often has to be sectioned, thus allowing the biting surfaces to come together. Some dentists allow the teeth to passively erupt to come in to place, which to me is way too arbitrary. Why would you spend months in these appliances to let the bite come together on its own? More experienced clear aligner providers will therefore section the tray and apply buttons and elastics to the teeth to help close the "open bite" that often happens during this treatment. Some even tell their patients to expect a period in their treatment where they have to wear traditional braces to complete the movements that are just too challenging for the clear aligner systems. This means that someone providing clear aligner treatment must have a good working knowledge of traditional orthodontics if they really want to be providing their patient with the best treatment possible. 3. Many of the systems require minimal training. Orthodontics is complex dentistry; there is no arguing that. If someone tells you that orthodontics is simple, they have not seen the negative outcomes that can happen with poorly executed clear aligners and traditional orthodontic appliances. Many of these clear aligner systems, however, require minimal training to start providing these treatments. It is usually as simple as taking a one day class, learning the submission protocols and technical requirements and you are good to go. There is no requirement of proof of competence in traditional orthodontic theory or techniques to be able to start moving peoples teeth with these clear aligner systems. My orthodontic training consisted of me sitting upstairs in graduate orthodontics "observing" the graduate students bonding brackets, and at most making a couple of retainers. Yes, I took the Invisalign course and I even started a couple cases in the clinic under the supervision of someone who had completed thousands of cases in her own practice. But.....do you really want me moving your teeth? No way. Go to someone with way more experience and training. I am considering getting clear aligners, what should I take into consideration? Be an informed consumer. Ask questions. Would traditional braces be better for me? If the answer is no right away.....that raises a flag! Will I need buttons or elastics? If the answer is no.....then ask how they plan on finishing the bite, considering the trays cover the biting surface. Do you do traditional braces? If the answer is no, they may not have the background knowledge required to fix things if the case starts going the wrong way. Many dentists get to be pretty good at clear aligners by trouble shooting cases and going to study clubs, and there are many non-orthodontists that are very competent providers with advanced skill sets in clear aligner treatment. But, this comes with time, with the experience of working through many cases, and with the participation in lots of continuing education. Not everyone is there though.... The reality is that when the treatment starts straying away from what was planned, all the novice user has to do is "reboot" the case. These clear aligner companies have made it really simple for dentists who have little to no experience in traditional orthodontics to provide treatment. If things start going awry, all the dentist has to do is to take new impressions and new records and order a whole new set of trays. And then repeat until close enough. That is not orthodontics. Should I see a specialist? Always consider a consultation with a specialist when you are contemplating complex dental treatments such as orthodontic tooth movement. Yes, general dentists can get the training and skills required to perform these advanced procedures, but there is no harm in getting the opinion of a certified specialist before starting your care. Every good general dentist should have a comprehensive group of dental specialists that they work with, that are part of their team, that are colleagues, and that are resources that help them provide better care for their patients. If your general dentist is hesitant to refer you for a consultation, you have to ask yourself why. There is a lot of competition in Vancouver, and people are afraid that they will "lose" the patient if they are referred for a specialist consultation, but it should not be considered so threatening. Getting a second opinion allows for a fresh look at the scenario, and can help identify potential challenges and limitations to the treatment options. Being informed is never a bad thing. Your smile is worth a consultation with a specialist. Thanks for reading! Please like, share, and follow along. Dr. Dave Certified Specialist in Prosthodontics drdave@alfaropros.com #Orthodontics #Invisalign #DrDave #SpecialtyDentistry