I do not know if it is the increasing number of candles on my cake each year, or if my friends have had a recent bout of bad dental luck, but lately, I have been getting this call a lot: "Yo....Dave......my dentist says my tooth is broken and I need an implant. They have a specialist that can do it for me. Do you mind taking a look?" This makes me both very sad and very happy. Of course it upsets me to see that my friend has a busted tooth, but what I find great is that they had the foresight and willingness to go a specialist for a second opinion. But are people being referred to specialists for consultations for complex dental care? Let us talk "second opinions". There was an era in Vancouver when general dentists referred to prosthodontists for their complex occlusal rehabilitations, dental implant restorations, difficult crown and bridge cases, and of course, dentures. The golden era had big names who were local pioneers in dental implantology, and were instrumental in developing the interdisciplinary study club culture that is so prominent in Greater Vancouver today. But things have changed. Everyone has become a specialist. Who exactly are dental specialists? The College of Dental Surgeons of BC has recently implemented a very big change in advertising regulations: we dentists can no longer list credentials on any of our promotional materials or professional communications. Read: CDSBC Promotional Activities Decision Those changes mean that even though I have a Masters in Craniofacial Sciences, a Diploma in Prosthodontics and have succesfully completed board exams that allow me to hold a Fellowship in the College of Dental Surgeons of Canada (making me an actual specialist).........I cannot put them on my business cards anymore. My name now has to read: Dr. David P. Alfaro, Certified Specialist in Prosthodontics I am allowed, however, to list my creditials on my website, or in a text paragraph on my promotional materials, with strict formatting guidelines. The intention of this change makes sense, because things are really clear; either you are licensed as a general dentist, or as a specialist. No more confusing acronyms. What dental specialties are truly specialties? One of the reasons these new regulations came about was because people were advertising themselves as specialists in specific treatments that are not officially recognized as specialties in BC. There is no such thing as an "implant specialist". The same goes for a "TMJ Specialist"....and there certainly is no specialty of "cosmetic dentistry". But if you read bios, and look at the names of dental offices, you will see that people often state that they are "specialists" or "experts" in something......then you look up the registration of the dentist, and they are licensed as general dentists; these people are violiating college regulations and are decieving the public. This is not a problem limited to general dentists either; specialists have been just as guilty of calling themselves things that we are not allowed to call ourselves, such as implant specialists. Yes, we may be very experienced and trained in dental implants, but the rules state that we must call ourselves specialists in our specialty. Can my general dentist do this treatment? Many of my general dental classmates from Columbia often get in this debate with their specialist friends. The real answer is: of course, a general dentist can do whatever he or she feels comfortable treating. But it comes down to training. Unfortunately, my Columbia classmates are a bit blinded to the reality that we went to a top tier program and that other dentists from other programs may not have had the exposure to advanced dentistry that we did. So they are quick to step to the defense of the general dentists in this oft heated argument of who should be performing complex dentistry. At Columbia, from day one we were volunteering and shadowing in the full spectrum of specialty clinics, we were encouraged to do externships, we had mandatory hospital based oral surgery rotations, we spent one day a week in fourth year rotating in hospital based general dentistry residencies, oh..... and were taught by some of the top specialists in the country. To top it off, 95% of graduates end up completing a minimum 1 year of residency. So yes....we Columbia grads can feel pretty comfortable tackling complex dentistry. But......you don't know what you don't know. We assumed that every program was like that, but, it wasn't until I spoke to graduates from other schools, and was validated when I taught in a dental program myself, that I realized how far ahead I was right out of Columbia. I mean, I did not do more crowns, or bridges or fillings than graduates from other programs, but from day one I was observing and assisting in IV sedation sinus lifts, implant surgeries, lateral ridge augmentations, complex endodontics, connective tissue grafts....tough stuff. It was ingrained in us that dental school teaches you the basics, and that you go to residency to prepare you for clinical practice. That opportunity is just not offered at every dental school. But we didn't realize it at the time, and we sure complained about our experiences then! Man was I a spoiled brat. The reality of most dental programs is that general dentists finish school having spent perhaps a fragmented 2 years actually doing clinical dentistry, and they may never have assisted in an implant surgery, or even worked with implant dentures, crowns and bridges. Forget sinus lifts. You would be lucky to get some classic perio surgeries completed, but lateral ridge augmentation? Nope. Ortho? Maybe. When I was in residency, and in the time I spent teaching at the local dental school, I encouraged students to come and shadow me, and definitely suggested that they complete a residency of some sort. But at the local program where I was, historically there were only a handful of students that would actually go on to advanced training. Unfortunately, the students think that the experience required to tackle advanced cases will come in private practice and in study clubs and lectures. Dental continuing education, however, is not the same as a residency. Period. Only those who have completed a residency will understand. Again....you don't know what you don't know. Why does this matter? I agree with the college on this.....it is about protecting the public. If someone is calling themselves a specialist in something, they better truly be a licensed specialist in that field. Too many times do I have patients coming to my office for a second opinion from the "implant clinic in the mall", or telling me that their general dentist was going to bring in a "specialist" to do their implant.... and then I do the research......and the person is licensed as a general dentist..... What am I supposed to do? Talk about an ethical dilemma. I started off my career by treading lightly, but the problem is so ubiquitous that I stopped keeping my mouth shut. The patient needs to know: that doctor is not licensed as a specialist. They may be VERY good at what they do, and may be very capable of taking on challenging cases....but that does not make them a specialist, nor should they be advertising themselves as one. You have to be licensed as a specialist to truly be one. When someone is licensed as a specialist, you know that they have completed at least 2 or 3 years, and thousands of hours of advanced university level training beyond their dental degree, and have passed a rigorous set of written and oral examinations to be able to be registered as a specialist. For general dentists who are tackling complex dentistry such as dental implants, bone grafting or orthodontics, there is no way to confirm their training. A mini-course on dental implants is way different than a 3-year residency and masters, and having to pass a structured, ridiculously difficult licensing exam for specialists. Providing Invisalign or Six-month Smiles is not the same as being an orthodontist. There is a broad range of training available to general dentists via continuing education. There are programs as simple as taking a weekend cruise and popping some implants in a pig jaw, but hopefully people enroll themselves in one of the more structured programs that are available. These programs can range from 10 days to 30 days of training, and cost the dentist tens of thousands of dollars to take. These programs can get "accreditation" from continuing education societies, but are not equivilent to an accredited dental residency, and certainly do not qualify people for licensing as dental specialists. So yes, there are some very well trained dentists out there that have pursued advanced education in a responsible manner. But no matter how you look at it, even if you take a 30 day implant course, and frequently place dental implants, that amount of training does not compare to a 3 year residency, completing a board exam, and then running a speciality practice where you deal with complications every day. Why am I being so cranky pants about this? Unfortunately, my specialty has become a graveyard for failing dentistry. I do recognize that I am getting the outliers and that a majority of dental work completed in Vancouver is well thought out and performed by competent individuals, but, as a specialist in prosthodontics, I have nightmare problems walking in to my office every day. I get it, sometimes things just go the wrong way. But....more often it is tourism dentistry or someone trying to save a buck somewhere, and sometimes, the dentist was taking on a case without realizing the hidden challenges. If you ever hear someone say that dental implants are easy, or that invisalign is easy, do not believe them. There is no such thing as a "slam dunk" case. If you think that, you simply have not seen the failures that I have seen, even in those cases that should have been dunks. People don't know what they don't know. I blame the market pressures of today. Vancouver is supersaturated with dentists. There is so much competition in this city that some people would rather take on a case that is beyond their skill set, just to ensure that the patient does not go somewhere else. If they can't do it, they will bring someone in to help them, often a rep from an implant company, a lab tech, or another general dentist, but rarely an actual specialist, because for some reason, there is this huge disconnect between specialty and general dentistry right now. So what can the public do? First of all, never jump into a treatment without fully looking at all of the options. Second, if you are told that you are being sent to a specialist, make sure that they are a specialist! If you are being sent to another general dentist, that has to be made clear to you. It is not to say that the general dentist is not skilled, but it is about the actual licensing status. Specialists are specialists and general dentists are general dentists. We need to clear up any confusion. Look up your dentist's registration status here: Registration Status (They didn't make it easy, you have to go to +more search options to find a specialist) Lastly, go for a second opinion. I know people who spend hours rearching and pondering a gadget or a pair or running shoes, but when their dentist says, oh, you need braces, have you considered Invisalign? They do it without checking with anyone else. How does that make sense? Go ask a specialist. Go back to your general dentist. A good general dentist and a good specialist will work as a team. It is worth the consulatation fee to get a specialist's opinion on complex dentistry, and believe me, implant dentistry and orthodontics both qualify as advanced dentistry. And if you go somewhere that does free consults, great! Then go for a third and pay for it. Take your time before you decide to make a permanent change to your face. Being informed is paramount! If you don't know......now you know! Thanks for reading! Please like and share! Dr. Dave drdave@alfaropros.com Certified Specialist in Prosthodontics #DentalImplants #SpecialtyDentistry #Referrals #Invisalign

It has been a long time since someone has asked me to write about something! A good friend from back in my Cactus Club days is wondering why dental anaesthesia doesn't seem to work well for him. This is a difficult topic that is still very mysterious. Let us talk about dental "freezing" (getting ya numb, for my US friends). What is pain anyways? We have all been in physical pain at some point, but how well can we describe it? It is a hard thing to get a grasp of because pain is not just a sensation, it is an experience. Pain perception is affected by local factors at the site of the injury, there are areas in the spinal cord where modification of the pain signal occurs, and then centrally in the brain there are further interactions that can alter the feeling that happens in response to a noxious stimulus. The extent of pain that felt is therefore very different between people, and within people, depending on a whole set of parameters that can even include emotional state, awareness, and previous experiences. Pain's complexity makes it very difficult to study. It is not as straight forward as studying a drug, where we can administer a specific dose, measure the amount in the blood stream, evaluate outcomes numerically (such as blood sugar levels), and then come up with confident conclusions about the effects of the treatment. A pin prick to one person could be no big deal, but for someone else could be a horrible, traumatizing experience. How do dental local anaesthetics work? Getting people out of pain, and preventing pain, are some of the major stressors that I experience every day as a dentist. It is emotionally draining knowing that every single person that comes in to my office has some level of anxiety and is not looking forward to the pain or the numbness of freezing, and in the case of surgery, the days of healing that are required. It hard for us dentists too; I do not like inflicting pain, but it is an often unavoidable part of my job. If if wasn't for gloves and local anaesthetic, there is no way that I would have become a dentist. I will skip the history and pharmacokinetics of local anaesthetics, but basically they work by shutting down the nerves that transmit the pain signal, along with the sense of touch. Nerves transmit impulses by allowing ions to cross their membranes, causing a change in voltage. Local anesthetics block the ion channels leaving the nerves unable to transmit the electrical signal. There are different anaesthetics that vary in how strong they are and how long they last, based on various things such as how easily they enter the nerve, where and how quickly they get broken down, and whether or not they also have epinephrine (adrenalin). Why would someone have a hard time getting "frozen"? There a many reasons why there could be difficulties in acheiving profound dental anaesthesia. 1. Injection technique and anatomic variability There are various ways to apply local anaesthesia: we can target nerves directly, we can infiltrate the anaesthetic to the bone that surrounds the tooth, and we can even inject the solution into the periodontal ligament space or into the pulp itself, if it is already exposed. All of these techniques have different indications, success rates, complications, and discomfort levels. When most people think of getting a "shot" at the dentist, they are thinking of the inferior alveolar nerve block. There is a pretty big nerve that enters the mandible on the inside of the cheek, very far back. Like most big nerves, it runs with blood vessels in a bundle. This nerve supplies sensation to most of the lower jaw and teeth, one on each side. To successfully "block" this nerve a dentist has to deposit the anaesthetic solution right beside the nerve. Even with proper training, it is possible to "miss the block". Depending on the study, and type of anaesthetic used, research indicates that it could be around 25% of injections that fail. 2. Local Factors When there is an active infection or inflammation, the nerve does not respond well to anaesthetic. It is well documented that people with teeth that are "symptomatic", have a harder time getting frozen. There are many possible reasons for this, including local changes in pH, high concentrations of inflammatory mediators, increased regional blood flow, and potentially even changes to the ion channels themselves. Read: Anaesthetic for "hot" teeth 3. Systemic and Central Factors Some people just gobble up anaesthetic. They get nice and frozen but then it wears off quickly. This again could be for various reasons. As most modern dental anaesthetics are metabolised in the liver, anything that ramps up liver enzyme function can theoretically speed up the rate that these anaesthetics are broken down. There are individual differences in pain tolerance as well, and there are various theories, ranging from very biological explanations such as variations in receptors and ion channels, to more psychobiological explanations, where experiences and emotions cause the upregulation or downregulation of enzymes and receptors involved in the interpretation of the pain experience. Some people tolerate pain well, while others flinch at every light touch. Are there risks to local anaesthesia? Of course. Everything has its pros and cons. Whenever any medication is administered, there is always the risk of allergy or sensitivity to the drug or its byproducts. Fortunately, most commonly used local anaesthetics and their preservatives are very well tolerated. Depending on which anaesthetic is used, there can be serious adverse effects such as cardiac arryhthmias or seizures if administered in high doses. Many of the reported adverse outcomes could be related to the addition of epinephrine to common local anaesthetic solutions. It is added in order to constrict the blood flow in the region where it is applied, helping to keep the anaesthetic in place, instead of allowing it to diffuse systemically. It also helps provide hemostasis. If too much epinephrine is used, or if the injection is deposited within a blood vessel instead of within the tissues, patients may experience increases in heart rate and blood pressure. Finally, there is always the risk of nerve damage and needle breakage when an inferior alveolar block is performed. The risk of the anaesthetic itself damaging the nerve is not the concern here, but it is the needle itself. When administering a "block", the dentist must blindly place the needle close to the nerve. We obviously cannot see the nerve, but use anatomical landmarks to estimate where the nerve should be. Then the goal is to aim for right beside the nerve; we do not want to hit the nerve or blood vessels, but to get it close by. This is tough to do and contributes to the low success rates of the inferior alveolar nerve block. Sometimes we are too accurate and hit the nerve straight on with the needle. Patients will often report a sharp electric feeling when this happens, and really there is nothing that a dentist can or cannot do to avoid this. Most of the time this is just a zinger that goes away quickly, but some patients can experience lingering altered sensation that could even last for months. Fortunately, the nerve damage is rarely permanent. Read: Cardiovascular risks of local anaesthetic What can a dentist to do provide better anaesthesia? Technique and anaesthetic choices aside, the provision of efficient dental anaesthsia is truly an art of patience. When I was a kid, I was pretty good at the dentist, but was still not too keen on getting shots or drilling done. At the office I went to, and at many other offices, the dentist was always rushing around treating a bunch of patients at once. To me, this was a source of stress. I was totally fine chatting with the assistant and hygienist, but I knew once the dentist walked in, that it was pain time. Furthermore, he didn't really say anything to me. He would ask the assistant, "is he frozen?" and would then just do some stuff then walk away. If I wasn't frozen, he would just load me up with more, and then would walk off to do something else. After having had that experience growing up, I decided that I would not practice dentistry that way. The administration of anaesthesia and anxiety management is something that I take my time with, and I am fortunate that I can do that in my practice. I do not have multiple appointments going on and my patients get my undivided attention. It is how I manage dental anxiety and how I ensure that my patients are comfortable before beginning any procedure. What about sedation? Vancouver is completely saturated with offices promoting sedation dentistry. I have even seen "Dentistry while you sleep!" ads on the bus. Yes. I take the bus and skytrain to work. Don't get me wrong, sedation has a very important role in the provision of complex dental care. It is a great tool when dealing with a combative patient, or when completing larger, invasive, dental surgery.....but....people are using sedation as a primary anxiety management technique, and even worse, as an income generator. Sedation is safe, but when things go wrong, they go very wrong, and the bottom line is, the general population does not need sedation for their basic dentistry. Sedation adds a whole layer of complexity to the provision of dental care. It adds a new element of risk to every procedure. Instead of worrying about the challenges of the dental treatment that is being provided, the risks of the sedation become the greatest concern, and procedures need to be completed as quickly as possible. I do not understand how anyone would be willing to add so much risk for dental procedures that can be completed with basic local anaesthesia. I can say this comfortably because I do complex prosthetic and surgical dentistry everyday, without sedation. Extractions, dental implant surgery, bone grafting, multiple crown preparations. Hard stuff. Yes, I have had patients who regularly take anxiolytics ask if they can take one before an appointment, but I do not even have a stock in the office, nor do I need to. If someone absolutely insists on sedation, I refer them to the appropriate specialist. In my practice, I manage dental anxiety without the use of drugs. I book extra time, I let patients rest, I make sure that I give them time to ask all the questions they need, and I sit by their side until they are calm and comfortable before starting any procedure, even for something as simple as a scaling and root planing. It is takes time to provide dental care in this manner, so yes, people pay specialty fees, but they get specialty care. And for the most part.....it works. Read: management of dental anxiety adult dental anxiety dental team behaviour and dental anxiety in children This kind of treatment just does not work out in an office like I went to as a child and teenager, where the dentist was running from room to room doing fillings and hygiene checks. He did not have time to even talk to me directly, let alone sit with me while the freezing took effect. In a busy, volume based, general dental practice, anxiety cannot be managed with time the way I do in my little specialty clinic. Adding sedation to manage dental anxiety to a busy routine like that doesn't work either, because sedation requires one on one attention. This trend of the incorporation of complex dental treatments (such as sedation) to the busy routine of restorative dentistry oriented general dental practices is a whole different topic, and a controversial one at that.....so I wont go there...... Thanks for reading! Dr. Dave drdave@alfaropros.com #AskDrDave #PainManagement #anxiety #sedation

I am sure that every dentist out there has had a patient present with a main concern of, "my naturopath told me to get rid of my dental amalgam because of the mercury." Or, "I read on this health website that my dental amalgam is going to give me Alzheimer's." Thank you internet, you make my job harder. There really is no debate about it. Yes, there is mercury in dental amalgam, and yes, it can enter the bloodstream. Whether or not it is actually causing all of these problems, however, is debatable. Regardless of one's stance on the health effects of dental amalgam, we have to take a look at the alternatives that people are choosing when removing their metal fillings. Are they any better than the mercury laden restorations of yore? Let us talk about "white fillings". What kind of dental fillings are currenty available? Dental amalgam has a long history in dentistry. It is an alloy that consists of mercury, tin, copper, silver and other metals depending on brand and properties. Amalgam has long been considered the gold standard, and many people still use it today. This type of material does not actually stick to the tooth, but stays in place because of the cavity preparation design. It is for this simple reason that I do not use amalgam in my office. When we prepare a cavity for an amalgam filling we have to create a hole in the tooth that is wider at the bottom than at the top, so that when the material hardens, it is locked in place. We therefore are creating a big hole in the tooth that is not actually related to where the decay is, but based on the properties of the dental material. White fillings on the other hand, are designed to stick to the teeth. Composite restorations have not been around very long. Yes, we have been experimenting with gluing plastics to teeth since the 50's, but clinically reliable results were not acheived until the early 80's, and those composites had pretty poor properties and were inferior to the metal version. Today's restorative composites and adhesive systems provide us with a treatment option that is equal to dental amalgam, even though many old timers still swear by the classic metal technique. Because the composite restorations stick to the tooth, we are no longer forced to cut huge holes in order to complete our work. We just need to remove the decay and then fill it. This allows for a much more conservative approach than what was done in the past. The more we learn about the longevity of restored teeth, the more we see that it is the conservation of tooth structure that is the key to tooth survival. What is in these composite restorations? We all know that people are switching to glass and stainless steel water bottles because of the potential negative health effects of plastics. Well I hate to break it to you, but those same "dangerous" plastics are in the fillings that go in your teeth. There are many older brands that had BPA in them, but since the news broke that BPA may be bad for you, manufacturers have wised up and are marketing BPA free composites. But realistically, if you look at the composition of these plastics, they are all potentially toxic to some effect. There is no getting around it. Furthermore, the plastic "composite" material does not stick to the tooth by itself; it requires a bonding system. The tooth is ionic, and has a charge, but the plastic does not, so we need an adhesive to make the two materials compatible. There are hundreds of brands of bonding systems, all filled with different solvents and liquid plastics that are key to the adhesion process. We simply cannot glue this type of filling to the teeth with out these chemicals. Many of these plastics, solvents and resins are toxic to human cells and lab animals in benchtop research, and are harmful if they enter the water systems. Read: Toxicity of Dental Composite Release of toxins by dental composite Composition of Dental Adhesives Mercury Toxicity What about natural fillings? Some of my patients have gone to "holistic" dentists who give them "biocompatible" fillings. There are dentists that make their patients go for bloodwork and allergy testing to make sure that they do not have reactions to the dental materials that are available. When I first encountered this, I was intrigued! Of course I want to find a natural option that is biocompatible and less harmful for the environment! So when I had a patient come along who was really cautious about the materials I was using because she had undergone this testing at a "holistic" dental practice, I called up the office to ask what they use. The exact same plastic material that I was using already. There is no such thing as a natural, holistic dental filling material. They are all either metal, or plastic. Yes, there is research going on to pick the least harmful plastics, but plastic is plastic. So please do not fall for this "holistic dentistry" marketing fluff. And PLEASE do not go on YouTube and try those homemade fillings. Of course you can make a natural paste that firms up to plug a hole in your tooth. But that material dissolves in the oral enviroment and does not properly seal the cavity to the bacteria that cause tooth decay. Even professional, high quality, dental fillings that are properly placed, have limitations in how well they can seal off the cavity, so a flimsy homemade filling simply doesn't work. Did I mention that it is zinc oxide that these hippies are using? Zinc is toxic too by the way...... So what are our options? As a dentist, I pick composite because it allows me to be conservative in my restorative approach, and I have to accept it for what it is. Yes, I use a BPA free material, but I know that the other plastics can be just as harmful. For larger fillings, I recommend that a patient get gold or bonded porcelain, but.....the cements are still resin based and use the same adhesives, and the cost is much higher. I absolutely do not recommend the removal of dental amalgam. If the filling is sound, there is no reason to remove it. First of all, we risk stirring things up. I have had patients end up with lingering tooth sensitivity in a previously asymptomatic tooth after a metal filling is cut out, and in a couple of instances to the point where a root canal filling was required. Second, the cutting out of dental amalgam liberates all of the mercury at once. It gets aerosolized and absorbed by the lungs with a very high efficiency, even if it is done under rubber dam isolation with good high volume evacuation. And the final reason is, well.....is what we are putting in there better? No. We are replacing mercury for plastic and both have potential negative health effects. For my patients, the best solution is to not get cavities in the first place. I focus on prevention at my practice, even though I am a specialist in replacing missing oral structures. In fact, it is because I see the complications of dental caries, periodontal disease, and dental work every day, that I constantly harp on my patients to improve their home care. Most of the disease I deal with in my practice is completely avoidable and is behaviourly acquired. Brush your teeth. Floss. USE FLUORIDE. Damn hippies and their fluoride avoidance. Fluoride is proven to reduce the incidence of tooth decay when used at over the counter concentrations, and those articles that claim that it is neurotoxic and lowers IQ are full of assumptions and unaccounted for variables. Read: Fluoride Toothpaste risks and benefits I did not really think that water fluoridation was so important, considering that most people brush with fluoridated toothpaste and visit the dentist.....but I was wrong. Even in an era where people have decent access to fluoridated dental products and professional dental care, the removal of fluoride from drinking water has caused an increase in tooth decay in Calgary. This is modern proof (although it also has its limitations) that fluoride has clinically relevant effects on caries risk reduction. Read: Calgary water fluoridation study And the biggest predictor of future tooth decay is a history of tooth decay. Thanks for reading! Dr. Dave drdave@alfaropros.com #DentalCaries #Amalgam #Composite #WhiteFillings #Hippies #HolisticDentistry #Fluoride

I could not come up with a quirky title for this. Again, this is one of those topics that has been trending on my social media feed for some time. Turmeric. People love this stuff! It cures gum disease, it whitens your teeth, it reduces inflammation, it detoxifies your third eye! Really? The best use I have heard of so far is putting it in margaritas. Wellness margs. Now that I get. Let us talk about turmeric. What is turmeric? Turmeric is the rhizome of the flowering plant curcuma longa. It looks like a really orangy-yellow version of ginger, and is often used to colour and flavour curries and broths. In addition to its culinary uses, turmeric has long been praised in Eastern medicine for having anti-inflammatory and analgesic properties. There are various chemical substitutuents of turmeric with the main ones being curcumin, demethoxycurcumin and bisdemethoxycurcumin. Does it really have health benefits? I have no doubt that natural products can have medicinal effects on the human body. So many modern medicines are derivatives of natural compounds that exist in the plant (and fungi) world; penicillin, aspirin, atropine, cocaine, etc. Tumeric has an ancient history in medicine, and has been researched for various purposes, ranging from aiding in depression, to reducing pain and inflammation in arthritis, for which it appears to work very well in comparison to analgesics such as ibuprofen. It has clinically been shown to reduce biochemical markers of inflammation. Read: Curcuma and arthritis Curcuma and inflammation Turmeric and C-reactive protein What about dental health? Just like coconut oil, people are putting turmeric on and in everything. This one video I saw had a guy brushing his teeth with it because it is supposedly good for a whole bunch of things, including removing fluoride, strengthening enamel, whitening teeth and of course healing your pineal gland. Comon. You have seen that stuff, right? It is brightly coloured! It stains everything! Do not go smearing that stuff on your teeth if you have plastic fillings. There are various studies that use turmeric to test the colour stability and stain resistance of composite and glass ionomer restorative dental materials because, well, it stains more than coffee or red wine. It is simply not a good idea to "whiten" your teeth with it. Read: Turmeric and resin dental materials Colour stability of dental materials Food staining of composites Turmeric does appear to have some antibacterial, antifungal, and antiinflammatory properties that have been evaluated clinically and in the lab. It has been shown to be effective at reducing gingival inflammation when used as a topical application during scaling and root planing. It has been shown to kill common endodontic pathogens (in vitro). It has even shown some positive outcomes in the treatment of inflammatory oral lesions such as lichen planus and fibrosis. Read: turmeric and periodontitis turmeric and root canal cleaning turmeric and root canal pathogens turmeric and oral lichen planus Maybe turmeric does have a lot going for it. But..... You have to look at the little details in the studies. In these clinical and in vitro trials, they are not just using dried and ground turmeric like you would sprinkle into a curry, but are using concentrated and processed versions. The studies that look at its topical use for gingivitis for example, process the tumeric into a viscous gel using various solvents. The studies that look at the systemic use of turmeric utilize concentrated capsules that have been chemically standardized to contain specific concentrations of the substituent curcumin, and at doses way higher than what would be used in cooking or as an addition to a smoothie. It is not the same as sprinkling a teaspoon into a lovely sauce. The reason that the researchers do this is because curcumin has a very low bioavailability; the body processes turmeric so fast that there is little actual curcumin in the bloodstream after ingestion. This reminds me of a martini infused conversation that I had with my best friend James, when we were at dinner and eating fabulous, juicy steaks. I was trying to be faecetiously philosophical about how the food that was in our digestive tracts was in our bodies, but not actually within our bodies. Only once something is absorbed, is it actually "in" the body. "whooa, so the food is in my body, but it is not" What happens to turmeric when you eat it, is that it gets absorbed, but then gets processed right away. If you look at research that evaluates blood concentrations of curcumin after the consumption of turmeric, it shows that at doses that you would find in meals (a teaspoon or two), the amount of curcumin that is found in the blood is negligible, and that what you really find are its metabolites. You only really start seeing curcumin circulating in the body at super high doses of turmeric (10 grams plus...which is like 4 or 5 teaspoons), and even then the amount is quite negligible. Clinical research therefore does not reflect the regular dietary consumption of turmeric. Read: curcumin bioavailability cucumin dosing This means that either you have to believe in homeopathy, where a microconcentration of a chemical is enough to cause the desired health benefit, or, that curcumin acts as a prodrug, meaning that one of the products of its metabolism is the active ingredient.....which has not been proven. That being said, turmeric has had some promising outcomes in various clinical studies, especially as an anti-inflammatory and analgesic. I would not go ahead to recommend using it as a mouthwash or toothpaste because it really does stain things. It is, however, relatively safe to add to your food and adds beautiful colour and flavour to sauces. Be careful in trying to up the dose to get the "health benefits", as has turmeric been shown to have gastrointestinal side effects and can cause allergic reactions. Read: allergic dermatitis I do not know if turmeric is the miracle root that all these internet health stars claim it to be, but it is certainly a yummy and beautiful way to add some colour to a dish. Will I start pounding back a couple of teaspoons of turmeric instead of an extra strength ibuprofen and an espresso after an evening of wellness margs??? Not likely. Thanks for reading! Please like, share and follow! Dr. Dave drdave@alfaropros.com #Turmeric #naturalhealth #oralhealth #hippies #food

Nerd Alert!!!! This is going to be extremely academic and boring, even for people in the dental profession!! Dentistry is historically full of concepts that have been passed down from teacher to student in a kind of folkloric tradition. Bennett movement. Ante's law. Posselt's envelope. Hinge axis rotation. Hanau's quint. The list could go on and on. Dogmas. As a dental student, I didn't really look deeply into how these concepts originated. I just believed them to be true because my mentors said so, and they were stated as fact in all of those famous text books we had to (and still have to) read. But then as I progessed through residency, and was exposed to more and more complex clinical scenarios, I began to question things. In medicine and dentistry, we are moving away from the teaching of traditional "accepted" concepts, and are looking toward evidence based healthcare to assist us in our decision making processes. After gaining a grasp of how to evaluate research, and how to apply those findings to my own clinical practice, I decided to go as far back as I could in the dental research literature to see exactly how the concepts that are so pervasive in our beliefs, came to be. So I read. And I read. And I read. I mean, I wasn't simply memorizing article authors and dates like what is required of us specialists for our board exams. It does us no good to pat ourselves on the back when proudly write down "Gargiulo (1961)", or "Fusayama (1979)", and act like we are all smart because we remembered who wrote what when. That is a superficial understanding of the history of our profession. Yet that often is how we are examined. In my trek through ancient dental research, I searched for original articles, I evaluated methodologies, I looked at statistics (when they were even present), I considered alternative hypotheses, and ultimately, I began to doubt many things that dentists treat as rules. I became the skeptic that I am today. One thing that I noticed as I read historical articles, was that more often than not, the papers usually had a hidden purpose of selling some sort of device. Sponsored content! The prosthodontic literature is absolutely FULL of these gadgets. For example, if you read the "classic" articles on occlusal vertical dimension, you will see that many of these techniques have a magic tool that will help you determine the correct place to put the occlusal plane; the Boos Bimeter, The Willis Gauge, The Boley Gauge, and more recentely the EMG (a la LVI).....again the list goes on and on. Not one of these is the absolute correct answer, but they will gladly sell you the device, plus shipping and handling. Technology has advanced far beyond the rudementary techniques that were available a hundred, fifty, and even twenty years ago. Publication requirements are also much stricter, and there are many more people doing research. So why do we still quote these articles, aside from their roles in history? Do we not have updated data? Fortunately, other skeptics have taken it upon themselves to re-evaluate the findings of the researchers of yore. The challenge now is that there is SOOOO much information. When we go to look at the research on a topic, we sometimes get lucky and find a systematic review or meta-analysis.....which often comes up with "the research is too heterogenous to come to a conclusion". But for those more obscure topics, we are often not able to find a well constructed review paper, and have to dig through dozens, if not hundreds, of articles. I hope that I am not coming across as an arrogant "know-it-all". I actually hope that it is the opposite; that you see that I feel that we need to question when someone says something very matter of factly, even if they are an authority on the topic. For example, I am sure that many of you have been reading those posts on social medial that are put together by a very popular study club. Some of those have been great technique pieces, others, simply biased. They recently posted an article on the NTI device. The author stated so matter of factly that the NTI separates the back teeth, thus relaxing the lateral pterygoid, allowing for the condyle to seat, reducing TMJ pain. But did they supply evidence? No. This is a topic that I would love to cover in the future, because I have read research (beyond what is quoted in Dawson or Okeson) and have been left thinking, "but.....maybe......" like the Louis C. K. bit. The author then went on to state potential adverse effects of the NTI, and included eruption of posterior teeth, and loss of habitual bite position. So it may work? But....it may also cause dental changes that would exacerbate the hyperactivity of the lateral pterygoid, if you believe in this concept in the first place. The stomatognathic system is a very complex anatomical and physiological mystery, which is attached to a highly emotional and often unpredictable mass of neural tissue, which in turn is affected by mood, experiences, fears, beliefs and even worse, can experience pain, which is the ultimate variable. It is easy for me to see why an intervention can work in one person, but can aggravate symptoms in another. There are no cookie cutter solutions. As important as evidence based dentistry is to our profession, we also cannot be dismissing the teachings of our mentors, because they have come from years and years of clinical practice. This mentor/mentee relationship must work both ways, however, where our senior dentists who have been practicing a specific technique for years, must also be open to changes in the practice that have evolved because someone took a fresh look at an old concept. And that is what nerds like me do. We read research. So I figured I would start a section to my blog which will cover different topics, looking back at the original articles, and at newer evidence, so we can all see how things have come to be and where they are moving to in the future. Nerdy, but useful. I hope. Thanks for reading! Please like, share and follow! Dr. Dave drdave@alfaropros.com #dogmas #nerdy #DentalResearch

Everyone has been talking about Coconut Oil. They are putting it in everything and on everything. I have heard of people scooping it into their coffee, using it as moisturizer and even swishing their mouths with it. So, I thought that I would look into this to see if there was any evidence behind the hype. Let us talk about Coconut Oil. What is Coconut Oil? Coconut Oil is obtained from the meat of the coconut through various methods. It can be removed by using solvents and other chemical treatments, or it can be pressed out, as in Virgin Coconut Oil (VCO). You will often see "hexane free" on containers of VCO to indicate that it was pressed, without the use of solvents. Coconut Oil has many components to it, but the main constituents are the medium chain length saturated fatty acids, Lauric acid (C12) and Myristic acid (C14). How is coconut oil absorbed and metabolized? Most fatty acids are absorbed into the lymphatic system instead of being directed to the liver for processing like most nutrients are. The lymphatic system then drains directly into the bloodstream, so fats enter the blood relatively unprocessed. There is evidence, however, that medium chain fatty acids, like those found in coconut oil, can be transported straight to the liver via the hepatic portal vein. This makes them available for oxidation more readily than other types of fats. Isn't saturated fat bad for you? Longitudinal studies such as the Framingham Heart Study have shown correlations between high cholesterol and saturated fats, with heart disease. The natural assumption would therefore be to think that coconut oil is bad for you because of the high saturated fat content. This may not necessarily be the case. There is plenty of evidence that coconut oil can actually improve blood lipid profiles by increasing healthy fats and decreasing unhealthy fats. After fats are absorbed, they are reorganized into different "packages" (not the technical term) that allow them to travel in the blood. There are groups of fats that travel in dense little packages (HDL: high density lipoproteins), and those that are less compact (LDL: low density lipoproteins). The ratio of HDL to LDL is an important marker of cardiovascular health, with higher levels of HDL being better for you. While there isn't enough evidence to make conclusions about the long term effect of coconut oil on heart disease, its HDL raising effects are promising. Check out these studies: Saturated fat and heart disease review Coconut oil and heart health Won’t eating fat make me fat? What makes people gain body fat is a lack of caloric output (sitting around on the couch) in comparison to their caloric input (eating too much). In order to improve one’s body composition, a healthy balanced diet and regular exercise is best! But….there are some foods that may be burned off more efficiently, and coconut oil appears to be one of those foods. Coconut oil has been shown to help burn belly fat! There are various studies that have shown that the addition of coconut oil to ones diet can not only help improve blood lipid profiles but can reduce waist circumference. Read: Coconut oil and waist circumference in coronary artery disease Coconut oil and obesity Furthermore, not only has coconut oil been shown to be burned efficiently, it may also help kickstart the oxidation of other fats. One group of researchers tracked how fats were burned in participants that included coconut oil in their diet, and found that not only was coconut oil more readily oxidated than other fats, but the rate at which the other fats were oxidated increased as well. Read: Coconut oil and fat burning But.......... while these are interesting findings, there is no magic elixir for weight loss. It is best to get out and do some exercise. What are other uses of coconut oil? I know people who use coconut oil for everything! They brush their teeth with it, smear it in their hair, rub it on their skin….the list goes on…..but does it work? or is it just hype? So…..like the nerd I am….. I looked it up and was again quite surprised. There are actually quite a few clinical trials looking at the dermatological applications of coconut oil. First of all, it has been shown to be an effective moisturizer with little allergic potential. This makes sense because as it is a saturated fat, it is very stable and does not need any additives or preservatives. Have you looked at your moisturizer? Even the “healthy” ones have dozens of ingredients. Virgin coconut oil is just that, coconut oil. Read: Coconut Oil as a moisturizer Not only has it been shown to be a good moisturizer, it can also be effective against some of the common skin bacteria that are associated with dermatitis, eczema and acne. Read: Coconut Oil for dermatitis I even found articles that showed that coconut oil was effective in protecting hair from damage if used before washing, and various articles that use coconut oil as an ingredient to fight lice. Coconut oil and louse Coconut oil as a conditioner Have you heard of "oil pulling"? Oil pulling is the practice of swishing sesame oil in your mouth in order to dissolve plaque and bacteria. I have read of people advocating the use of coconut oil for this purpose, but all of the clinical studies that look at oil pulling utilize sesame oil. So I can’t speak on coconut oil's actual efficacy for reducing caries or gingivitis, but IN VITRO studies prove that coconut oil can be antimicrobial against some of the bacteria and fungi that regularly colonize the mouth. Coconut oil vs S. Mutans and Candida After taking a look at the evidence behind coconut oil, it looks like it holds up its end of the bargain. Obviously, long term and large scale research is required to validate the findings of these few small trials, but for now coconut oil appears to be a safe and healthy product to eat and smear everywhere. The beautiful thing is that it is completely natural, and can survive with a pretty stable shelf life without the need for preservatives. No chemicals or additives! I didn't go in thinking that I was going to be a believer, but after doing the research.....I am pretty convinced…...I believe the hype on this one! For a good review on coconut oil read: coconut in health promotion Thanks for reading! Please like and share! Dr. Dave drdave@alfaropros.com #coconutoil #healthcare #fads #hipsterstuff

Anyone who has been following along on my blog, or on my instagram (@chubbychileno), knows that I love to eat and drink yummy things. During the year I consume a healthy supply of fat juicy steaks and cold crushable refreshments because, you know what? Food and drinks taste good and I like them. This time of year, however, the pants always seem to fit a little tighter. It was so bad last year that I had to go out and buy new work pants. My fat pants. I did not understand why......I was running 4 or 5 times a week and was feeling good, but the fat just stayed on. So I made a change. Let us talk about resting energy expenditure (REE). I have always been a gym rat. Back in my teens, I started hitting the gym to bulk up, as I was a scrawny 135 pounds. I lifted hard, but no matter what, I could not seem to break 165, when I really wanted to be 180. But, I was a teenager. I went to school, worked two jobs, and in my spare time was playing basketball, volleyball, hackysack and generally running around all day. Burning calories like I wish I had time to now. Then came real life, and even worse, I moved to America. Portion sizes, unhealthy options, lack of healthy outdoor space, a general lack of time (thanks to dental school) and unfortunately a seriously sprained ankle, caused me to balloon way past my goal of 180. And it was alllllllll fat. I did not really notice how fat I was when I was in New York because, well, people in America are just more robust than in Vancouver. I was fat for me, but was still thinner than most. Upon my return to Vancouver, where everyone is eating foliage and downward dogging all day, I noticed, hey....I am pretty chubs! I started running and biking and doing yoga because you know, if you don't run or bike in Vancouver, you just aren't healthy. And I started feeling pretty good. But I wasn't looking good. So.....I did it. It was a sad and dark time in my life. It kept me from spending time with my friends, and forced me into an unhappy place. I went on a diet (shudders). Dieting sucks. So I stopped. Who wants to limit themselves to lettuce, chicken breast and a small potato for every meal? I love beer. I can't have a beer? MMMMM chicken wings. Rib-eye. Homo milk in my cereal. I love that stuff. That is what makes me happy. I don't currrrrrrr if I have a belly. But my gluttany was going to force me to by a whole new wardrobe.....and I wasn't about to do buy all new clothes and accept my fatness. We all know the mantra, calories in/calories out. Just like all the other cardio freaks out there, I was hitting the treadmill every day trying to burn as many calories as I could. It was the perfect metaphor. I was chasing an imaginary goal, while not actually making any forward progress. The way I eat, there is no way I am going to burn those calories. Traditionally, weight loss programs have been focused on aerobic exercise, and low intensity high repetition resistance exercise (eg jogging and low weight/high rep weight lifting). You want to burn fat and shape muscle. This is what I was doing, but it was not working, and dieting simply is not realistic. But I thought to myself.....I do not spend most of my day exercising and burning calories, I spend most of my day "at rest". What if I could increase how many calories my body burns ALL OF THE TIME? There are different terms for this. Some people call it Basal Metabolic Rate and others Resting Energy Expenditure, and of course, nutrition and exercise nerds debate the definition. But for our puposes, lets just say it is the calories we burn in the background, when we are not intentionally exercising. What is Resting Energy Expenditure? Kind of how an idling car still consumes gas, at rest, our bodies need energy for all of the things that need to happen for you to live. Organs are working 24/7 and they need energy to do what they do, and they make up a big portion of the resting energy expenditure. Connective tissue is also metabolically active, and I am sure that all of you know that muscle burns more calories than fat does. Even the chemical reactions that happen in our body burn calories. How can we augment our REE? Well, there are many foods and supplements that you can eat that help you burn calories. Thermogenic aids raise your body temperature and therefore increase the calories your chemical reactions burn. There are foods and supplements that supposedly affect your organ metabolism too. A more realistic, simple, safe and effective approach to improving your metabolism is by increasing your muscle mass or your "fat-free mass". Is there evidence that increasing muscle mass increases baseline caloric expenditure? You know that I like to find meta-analyses and systematic reviews for the answers to these questions, but unfortunately for this specific scenario, the information just isn't available. I mean there are some, but for very specific populations, such as people with metabolic syndrome, diabetes or even burns. Regardless, there is good evidence that stem from individual clinical studies that show that building muscle mass with a dedicated resistance program increases baseline caloric expenditure, with positive effects on body composition. Read:Lift Weights to Fight Overweight What about aerobic exercise? We all know that "skinny-fat" person who can run 12 clicks without busting a sweat but gets tired lifting stuff. Yes, aerobic exercise burns a large amount of calories, and burns more than weightlifting alone. And yes, there is a post workout effect of increased body temperature which further augments caloric expenditure. But, is cariovascular exercise alone an efficient way of trimming the fat? Not really. It is just plain hard to keep up with caloric intake if you do not boost your metabolism. Aerobic exercise helps a lot with burning calories when exercising, but it's effect on resting metabolism is not great enough to help keep the weight down, unless you add a strict diet to the mix.....and that just is not fun or realistic. Read: Aerobic exercise for weight loss What about combining the two? The human body is not designed for monotony. People with dogs do not realize that their houses smell like dog because they have become accustomed to the smell. If you eat spicy food all the time, you get used to it. The body adapts. The same goes for exercise. If you run at the same pace, your body adapts. If you lift the same amount of weight, your body adapts. We need to be constantly changing the stimuli that our bodies receive in order for adaptations to continue. This is especially true in exercise and the science backs it. Combination exercises such as High Intensity Interval Training have been shown to allow for general improvements in body composition and athletic performance, and better than sticking to one modality. Yes, if you want to be an elite runner, or a power lifter, you have to focus on those skills in particular. If you are working out to keep healthy though, mix it up! Read: Different exercise modalities to fight obesity And that is what I did.... I re-introduced the teenage bulking style, heavy-weight, lifting protocol. It seemed counterintuative because I was technically burning less calories per workout, but it worked. I have jacked up the weights and made sure that I covered every muscle group at least two times a week, and I changed my cardio from boring hour-long snoozefests, to short duration, high intensity, heart pumping, adrenalin and endorphin releasing sprints. It has made a difference for me, and the true test has been this holiday season. I am still battling the bulge, but it has been easier this year and I am more confident that I can go out and feast on all of the yummy meals, mulled wine, and bailey's coffees I want without feeling guilty because my clothes wont fit. I just have to go hit the stacks to balance things out. Thanks for reading!!! Please like, share and follow along! Dr. Dave drdave@alfaropros.com p.s. please see a personal trainer (with a kinesiology degree of course) if you are considering starting an exercise program. #DietandExercise #chubbychileno #Nutrition

Another ask Dr. Dave! My good friend Mike came up with an excellent question regarding the role of opioids/opiates in dental pain management. Historically, it has not been uncommon for dentists to prescribe Tylenol with codeine, or even stronger drugs such as Vicodin (acetaminophen and hydrocodone) or Percocet (acetaminophen and oxycodone), after painful dental procedures such as third molar extractions. But what is the evidence to support this line of pharmacotherapy for the management of dental pain? Let us talk pain management. What are opioids and opiates? Opioids and opiates are drugs that are derived from the Poppy plant, and directly block pain receptors, so they are very effective at relieving all sorts of trauma induced unpleasent sensations. Examples would be codeine, morphine, heroin, oxycodone etc.... Depending on which drug, however, they also block various other receptors, causing untoward effects such as respiratory depression, constipation and itchiness. They can be addictive, and can be very harmful if taken in large doses or if mixed with other drugs, such as alcohol. Read more here: https://en.wikipedia.org/wiki/Opioid What kind of drugs do I prescribe to control dental pain? Going to the dentist is not fun. People can be quite sore after something as basic as a filling, or a deep cleaning. Then there are the procedures that definitely suck, such as having wisdom teeth removed, or gum grafting. At my office I do a lot of surgery. It is rare for a day to go by where I am not taking someone's tooth out, or placing a dental implant or performing some sort of gum surgery. My patients come in knowing that they are in for a couple of unpleasant days after I am done with them. The reality is, however, that even with all of the big procedures that I am doing at my office, I hardly ever prescribe pain killers any stronger than Advil or Tylenol. If I know that a procedure was difficult, or if the surgical site was open for a long time, yes, I will prescribe Tylenol with codeine, but I will inform the patient to start with Advil, at the regular precribed dose on the package. If that does not suffice, I then suggest that they supplement their pain management by taking Tylenol, half way between their Advil doses. This offers them a higher level of analgesia, without exceeding the recommended doses, using pain killers with different mechanisms of action. It is rare for me to have a patient tell me that they needed to fill the prescription for the Tylenol 3, and it is usually only for the first day or two if they do have to resort to it. Is there evidence for this approach? I was quite surprised at the scarcity of evidence looking at dental pain control. When I wrote my blog post about Tinder, I found hundreds and hundreds of articles. Dental pain management, on the other hand, had very little for me to sift through. Pain is a difficult concept to study because it is not easy to measure, and the results are inconsisent between, and within, people. Pain is an experience. It is something that is affected by both physiological and mental factors, so it is very challenging to standardize both the stimulus and the evaluation of the response for a properly designed research project. The vast majority of dental pain management articles that I was able to find were studies that looked at pain control after third molar extraction. Even though these articles look at one specific procedure, it is still difficult to standardize, because there are various variables that can affect the amount of pain that someone may experience after this surgery. One of the most important factors is operator experience. A dentist that knows what he/she is doing can perform the procedure in less time, with less damage to the bone, gums and neighbouring teeth, in comparison to someone who is just starting off, or who performs the procedure infrequently. I do not take out impacted wisdom teeth because of that exact reason. I refer to someone who does it all day, every day, or who has been doing it forever. It costs my patient more money, but it is better than me mucking around back there for an hour when an oral surgeon can shuck them out in fifteen minutes. In the end, the patient appreciates it. Nonetheless, there is enough research to be able to take a look at the efficacy of different pain management strategies, and it tends to support my approach of avoiding strong drugs. NSAIDS (non-steroidal anti-inflammatory drugs) have been found to be very effective at controlling dental pain from third molar extractions, which is one of the more uncomfortable procedures that can be experienced at a dental office. The addition of narcotic analgesia, does impart a minimal improvement in pain control, but at a cost. The side effects of constipation and drowsiness are real, and the risk of addiction is high. I therefore avoid the prescription of these medications if the patient can manage things with Advil and Tylenol. Read: Pain killers for 3 molar extraction in Dentistry Review Non opiod pain killers in dentistry Ibuprofen vs Ibuprofen and codeine Advil combined with Tylenol Addiction is a serious concern. Drug seeking behaviour is something that all medical professionals have to deal with, and it is a condition that is challenging to detect. Pain is a significant symptom that must be treated, but we have to be cautious as professionals to properly assess those patients that may be looking for more than pain management. Ultimately, I approach pain control beyond the pharmacological tools at my disposal. As I said, pain is an experience. It is something that is not just affected by how much bone you have to cut or how big of a flap is reflected. It begins with the first conversation you have with the patient, and continues with with good anxiety control techniques, and ultimately culminates in the need for quick and effective surgical skills. One of the great things that I appreciate about how I have structured my office is that I have the time to coach each and every patient through every procedure, regardless of how "simple" it may be. I have the time to give patients the opportunity to get comfortable and to relax, even if it is just by me sitting with them quietly as they get their nerves down. I know that I would not have the time to do this if I was running a traditional general dental office, where there are multiple patients being treated at the same time. As a specialist, I am able to book patients one at a time, for as long as they need to feel comfortable. I often book people extra time beyond what is needed to physically perform the treatment, in order to give time for patient management. Yes, my patients do pay specialty fees which are above what they would pay in a traditional general dental office, but we are in an era where people pay a premium to have the newest phone, or to drive a nicer car, or to get a better hair cut. Why should dentistry be different? If this sounds like something you want out of your dental office, please come and visit! I even do the cleanings myself. #sponsoredcontent haha ;) Thanks for reading! Please like, share and follow along! Dr. Dave drdave@alfaropros.com #askDrDave #PainManagement #Drugs

My morning routine usually includes having a yummy espresso whilst catching up on my social media feeds. A favourite page of mine is The Peak 102.7, because they are totally the best. But earlier this week they posted something that I had to blink twice at: A stuffed squash pretending to be Turducken. Whaatt?? No. They posted a recipe for a stuffed gourd and people were actually comparing this squash to the culinary delicacy of three yummy creature carcassess wrapped in a tight embrace and roasted to perfection. The comment section was full of people gushing and gushing over it. "OMG looks so good. I am totally gonna make it." "Too bad it isn't vegan!".....YEA! Let's make this EVEN WORSE. http://www.thepeak.fm/james-sutton/2015/11/09/meet-the-vegducken-the-ultimate-vegetarian-main-dish-for-the-holidays- Ok, I am overreacting; that did look pretty damn yummy.....but...as a side dish. A meal needs to have protein, and vegetarians just don't get enough. Let us talk about vegetarian protein sources. Why is protein important? When people think of the role of dietary protein in human metabolism, they usually think of muscle building. Dietary protein, however, is much more important than that. Proteins are comprised of smaller amino acids, some of which the body can make on its own, and some that must be obtained from food. These amino acids are used not only to build muscle, but make up the enzymes that fuel important reactions involved in immunity, cognition, energy metabolism, catabolism and anabolism.....pretty much every process in your body. A diet that includes complete proteins is extremely important. How much protein should we consume? The American College of Sports Medicine recommends 1.2 to 1.7 grams of protein, per kilogram of body weight, per day, depending on the type and intensity of exercise you are doing. Yes, these values are for athletes, but if you want to be healthy, you need to exercise, so these values should apply to everyone. Read: ACSM dietary guidelines If you have not poked around their website, do it! It is full of awesome, research-based information for athletes. http://www.acsm.org/ What about vegetarian sources of protein? Vegetarians and vegans are avoiding one of the easiest ways to get complete proteins in a nutritionally dense format: animal meat. Yea, I get it. They are cute. They suffer. They have feelings. But talk about a first class problem; most people in the world are starving! The internet is littered with articles that flaunt the latest vegetarian protein trends. This article even includes cocoa powder as a protein source: http://www.health.com/health/gallery/0,,20718479,00.html. Really?? Cocoa? Comon. Let's use me as an example to see how these "power proteins" stand up. Me: 85 kg. Chubby. Exercises moderately. Let's pick right in the middle of the range, so 1.5 g/kg/day. 85 kg x 1.5 g/kg/day= 127.5 g of protein a day. I have no doubt that I can eat 127.5 grams of protein a day on a vegetarian diet. It is possible, but what I want to see is exactly how much food is that going to be? People always post pictures of vegetarian weightlifters and endurance athletes, and even gorillas, saying stuff like, "powered by vegetables". Yea, they can be, but they probably eat thousands and thousands of calories a day. A regular human would become obese on that diet. To make things easy to read, I have put things in a table format, using information from one of my favourite websites, http://nutritiondata.self.com/. This table illustrates how much food and how many calories I would have to consume to meet my 127.5 g of protein daily goal. Now please look at this data seriously. If I was a vegetarian, I would have to be consuming RIDICULOUS amounts of food to nourish myself. 16 cups of quinoa? 10 venti soy milks? Enough chia to send me to the toilet for a year. That would only be ok if I was training hard, every day, burning thousands and thousands of calories, much like a professional endurance athlete or gorilla would be. But I am not. I am a regular human. Furthermore, most of these vegetarian proteins are great sources of dietary fibre, which is awesome in moderation. You guys would not want to be around me if I pounded almost 9 cups of beans per day. But then look at chicken. That is reasonable. I can easily have a chicken breast at lunch, and another a dinner, then sprinkle in a couple of other protein sources throughout the day, and EASILY and COMFORTABLY, attain my goals. It is simply not possible to have a balanced diet and meet your protein goals on a strictly vegetarian mealplan. If you try to, you will be sky high in fibre, carbohydrates and calories, and will be farting up a storm. Yea, go and take a hot yoga class when you have the trots from eating 6 times the daily requirement of fibre. Not recommended. Thanks for reading! Please like and share!!!! Dr. Dave drdave@alfaropros.com #Meat #SportsNutrition #Vegetarians #Vegans #Nutrition

Not one day after I posted on the internets that I am starting a section to my blog titled "Ask Dr. Dave", did I get my first questions! Of course, my lovely friends had to make it totally not related to dentistry, but you know what??? I am not afraid to venture out of my comfort zone, and I have the day off today. The question was....how does one succeed at Tinder? So....let us talk about online dating. Disclaimer! Unlike dentistry, I am not a certified specialist in relationships. Although Sheldon Cooper may disagree with me, the social sciences are research based, and there is a lot of information out there regarding online dating. Every species on this planet has predictable, yet evolving, courting patterns that have been studied academically. Why shouldn't the study of human online courtship also be scientifically valid? A recent systematic review took a look at research studies that analyzed online dating patterns, and they came out with some pretty great suggestions on how to land that first date. Here is a summary of what they found: Screen Name: It all starts with your online tag. Make your name desireable! Do not use negative connotations such as "little", as they seem inferior. Be playful. Guys tend to like screen names that imply attractiveness, such as "cutie", while gals go for the intelligent type, like "cultured", for example. Interestingly, researchers have found that names earlier in the alphabet tend to be more successful, and not just in online dating, but in other areas as well, such as education level and income. Search engines tend to pop things out alphabetically too, so pick a letter that shows up early. A creeper thing that was presented in the article was that people tend to pick people with names that sound/mimick their own name and interests, so get out there first, screen a buch of peeps and then pick a name based on what they may find attractive. Kathy Bates 2015 styles? #stalker. Photo: Post one where you are truly smiling. Sorry gals, duck face aint hot. Ladies, tilt your head a bit and wear some red....aparrently guys dig that. Also, do the creeper thing again! Check out some peeps and look at their profile picture, post something similar and they will be more likely to check you out. Headline Message: Do not be verbose and sesquipedalian (Thanks Miranda for teaching me that word in grade 9....I finally get to use it); people want to understand and remember what you say! If you can snag someone with your headline, and they stop and check out your pic longer....you are well on your way. Photogallery: Group picks. Don't just show selfies of you at the gym all by yourself. People want to see that a whole bunch of people like you, not that you like yourself a whole bunch. Men: post a pick with you and a bunch of smiling gals.....apparently women dig that. Make sure that you are in the middle of the picture and not off to the side, and try to find one where you are touching someone else....they both show confidence and that other people are comfortable with you. Description: This is where people make their judgements to move on, or to move forward. Make it realistic. Talk about yourself, but also talk about what you are looking for. The researchers found that a 70:30 ratio of who you are to what you are looking for tended to get the best results. Don't show off! Likeability is more important than academic acheivement..... hmmmm.....taking down my academic credentials from Grindr. Guys like seeing that you do yoga, that you do aerobic exercise and that you go to the gym, but they don't seem to like it if you play rugby or bodybuild. Girls like to see you being brave, courageous and outgoing, vs kind and altruistic. Wow ladies. Really? (Crosses off: volunteers at the food bank) How do you make yourself stand out when there are so many choices? Aside from attracting people with your photo and headline, use humour and proper spelling. Do not tell people that you are funny; say something funny. Do not shorten words or misspell things; it shows you either do not have the time, or are poorly educated. People can sniff out dishonesty a mile away! Avoid that. The first message: Do not go on and on about how amazing the person is and how much you have in common; people see right through that. Pick up on a couple things in their profile or photo and mention one or two in a breif message. Try to include something that rhymes with their name or headline....for some reason the researchers found that to work. Don't ask me why.....it's SCIENCE!!!! When you reach out, again, use light humour and ask open ended questions. If someone writes you, do not delay! Respond! If things go well and you strike up a conversation, do not lie! People can figure that out quite quickly, and remember, all they have to do is refer back to the history to catch you in a fib. Ask questions, be funny and confident, but do not be perfect. Nobody is perfect. Always end a conversation on a positive note, and if you hit it off, plan a to meet for that all important first date sooner than later. People who waited longer than 6 weeks to set up a date, were less likely to have that date actually happen. Stick on the ice!!!!! Just to recap.....these are not my opinions, but a summary of a research article. Overall, it was quite a quirky and well written paper, which was based upon a broad array of background research; check it out here: Turning that online contact into a first date Well....I hope you enjoyed my first "Ask Dr. Dave"....I am interested to see what other topics people are going to ask me to look up. I learned quite a bit.....I never have really put much thought into the science behind online dating. I thought dudes just swiped right until someone replied.... Who knew???? Thanks for reading Dr. Dave aka Lonelyshortnerdyboy_420 "will you share electrons with me? I am looking for someone to bond with" drdave@alfaropros.com #AskDrDave #Tinder #OnlineDating

"We specialize in making dental implants a painless & stress-free experience....." "Our doctors use the latest techniques and technologies to give you your new permanent teeth....." "Teeth in one day is the perfect solution...." I could go on and on and on and on...... These are just a few examples of statements that I see everyday in dental advertisements and websites for local dental clinics right here in Vancouver. I know that as a dentist myself, the big brother tools that social media applications utilize to target ads obviously direct more implant related traffic to my newsfeed, so I am probably exposed to more of it that the general population. But.....people come in to my office asking, "do you do the teeth in a day that I heard of on the radio?" Or asking if I can guarantee that their dental implant will be permanent and painless. Oh yea....and can you match the price of this dental office (whips out a coupon for an implant and crown for $2000)? So this type of dental advertising is obviously working. But we all watched Mad Men.....do you really want to be "sold" a dental implant? Let us talk about dental implants..... What is a dental implant? Humans have been trying to replace missing teeth for thousands of years, so dental implants are not really a new thing. After a bunch of failed concepts, the modern dental implant is a titanium alloy screw which is placed into the jawbone in a minor dental surgery. Crowns, Bridges and connections for dentures can then be attached to the implant. Have you ever hung a mirror with a drywall screw? It is basically the same process. You drill a hole in the drywall (jawbone), you put in that plastic thingy that embeds into the drywall (the implant), and then you screw a little screw into the plastic thing (whatever you want to connect to the implant, be it a crown, bridge or parts for a denture). It is a simple concept, but it is a VERY ADVANCED dental treatment. Modern root form dental implants were developed in Europe in the 60's and 70's, but it wasn't until the 1980's that the technique became widely accepted accross North America. They have not been around too long, and there has been a lot of evolution. Read:P.I. Branemark There are currently thousands of dental implant manufacturers across the world. It is a big industry that is spending big bucks trying to get dentists to use their products. Do dental implants work? This is a highly controversial topic in implant dentistry, and it comes down to how implant research is performed, and interpereted. I have to nerd out to explain.....sorry. During the infancy of dental implant research, the studies were just trying to prove that the implant fused to the bone; a process now termed OSSEOINTEGRATION. It was a new technique that was not widely accepted, so they just had to show, "Look! The implant is fused to the jaw!" A "successful" implant in those earlier studies was basically one that was fused to the bone. It could have been placed poorly, have gum disease (as long as it didn't hurt), and even have experienced what I consider to be a significant amount of loss of the supporting bone (up to 1.5 mm), yet if it stuck in place, it was successful. Furthermore, the failure of up to 15% of dental implants in a 5-year study of an implant system or technique, was still considered to be "successful". (Albrektsson Criteria) This is not success in my books. After it became clear that, yes, we seem to have a product that fuses to the bone, researchers started implementing stricter criteria for success. Unfortunately, there is no standardized criteria that is used across dental implant research to universally describe the "success" of a dental implant. Most studies now have some variation of a definition of "success", where they consider a successful implant to be one that is fused to the bone, has not experienced bone loss, is devoid of gum disease and is able to support a restoration. What about dental implants that did not work out perfectly, but still fused to the bone? In research studies, some of the dental implants fuse to the bone, but end up with long term gum problems, or may just not be in the right place to support the intended restoration. Since these implants have fused to the bone, according to the older success criteria they could be considered "successful", but realistically, they aren't. They have problems. Researchers have called this "survival", and this is what dental implant companies advertise when they are talking about how well an implant works. But this is not success! A patient with a "surviving" dental implant can have chronic inflammation around the dental implant, requiring constant attention and even surgical management. This is a very frustrating, time consuming, and financially taxing outcome. And it happens frequently. What are realistic success and survival statistics for dental implants? It depends on how nerdy you want to get. I am a bigtime nerd, so I look at the research and really try to compare things to the reality of my everyday practice. One of the first things that I look at when I evaluate any kind of article, is the "external validity" of the research. Most dental research is performed in highly controlled environments, where patients are carefully selected and monitored. Smokers, people with gum disease, people who have broken teeth due to bruxism (grinding), those who have had accidents, or people with certain medical conditions, are usually not selected for dental implant research. Furthermore, participants are kept to unrealistic standards of oral hygiene. Does this relate to who "needs" dental implants in real life? NO! It is smokers, people with gum disease, people with bad oral hygiene and those who have had accidents, that are most often missing teeth. Can I therefore take the findings of a research study and apply it to this group of people? No way! Then there is the heterogeneity of the dental implant procedure itself. There are thousands of implant companies, with thousands of designs. There are dozens of ways you can "restore" an implant. Surgical techniques and protocol are highly variable between practicioners, and ultimately patients are all different. You have to look up articles specific to your implant system, used the way that you want to, to understand the success/survival of the procedure. Are you going to read a review on the handling of a 4x4 SUV in snow, if you are looking to buy a hybrid city vehicle? Not likely. They both may have seatbelts, airbags, and headlights, but they aren't comparable. Dental implant companies are always pumping out new implant designs and restoration concepts. Long-term success articles (10 years or more) are therefore very rare, and often describe implants and/or techniques that have gone by the wayside. Many implant companies are promoting dental implants that have very little long term clinical research to support them. The first things I ask when a rep comes along pushing a new product are, "can you show me 5-year clinical trial data? Is there any ten year data?" Is that information in their shiny brochure with fancy images? Not often. They have to get back to me via email. Lastly, going back to success vs survival, there are various definitions on what a surviving dental implant is. Inflammation of the gums around a dental implant, is called "peri-implant mucositis", and loss of the supporting bone around a dental implant is called "peri-implantitis". There is no concensus as to how to define "peri-implantitis"; is bone loss without infection ok? how much bone loss is ok? will bone loss lead to infection? There is therefore a high variability in what researchers consider to be successful or surviving. With all of these variables, how can we in the dental profession make a sweeping statement with a specific number for implant success or survival? But that is what patients want to hear. If we look at a cross section of the dental research, we know that dental implants fuse to the bone at very high rates, in most scenarios, and even in very compromised situations. Unlike the earlier studies, where the loss of 15% of dental implants over a five-year study would be considered successful, we are seeing "survival rates" in the high 90's for almost every published article you can find out there. Yes. We know. Implants fuse to the bone. Where it gets muddy is when we look at implant "success". To me, and to my patients as well, a "successful" dental implant, is one that goes in without complication, heals without complication, fuses to the bone, allows for the placement of the intended restoration without modification or compromise in the design, and functions comfortably without pain, without gum swelling and without breaking of the prosthetic components or implant itself. I am going to drop a truth bomb here. Nothing works out perfectly in life, even dental implants. The prosthetic complications such as the chipping of a crown, or a loosened screw, yea they are a nuisance and cost money to fix.....but if you plan ahead for failure and inform your patients that it WILL HAPPEN at some point, they are easily resolved. Peri-implantitis, however, is a differrent beast, and it is out there. A lot! Depending on what definition the article uses, some researchers believe that around 1/3 of dental implants will develop some sort of gum inflammation around them during their lifespan. This is a shockingly high number that dental implant companies, and dentists, are not revealing when they use the term implant "survival". A "success" rate in the 60-90% range will just not sell dental implants, so people report the "survival rate", which may include these ailing dental implants. Read: 10 year implant survival and systematic review; note the high variability in success rate definition and therefore success rates, but high survival rates (table 4). Peri-implantitis and Peri-implant mucositis; note the variability in definition of peri-implantitis Frequency of Peri-implant diseases; note the difference in statistics between per patient and per implant What does one believe? With the correct planning, implementation and maintenance, dental implants can work very well, and are an excellent replacement for missing teeth. It takes years of training and experience to truly understand not just the successes of implant dentistry, but the challenges. A dentist working with dental implants must be comfortable not only explaining the potential complications that can arise, but should have a good understanding of how to manage them. I am not a very good sales person. I am not out there telling my patients that implants are "perfect", "painless" or "permanent". That is just plain misleading. Yea, I may not be "selling" as many cases as the guy/gal down the street, and I may not be doing the riskier "fancy" procedures, but you know what? I sleep well at night knowing that I gave my patients an honest opinion with realistic viewpoints of the challenges of implant dentistry. That is invaluable. Thanks for reading! Dr. Dave p.s this article just scrapes the surface on implant dentistry, if there are specific topics that you want me to cover, please send me a line! drdave@alfaropros.com #DentalImplants #Falseadvertising #beinformed #AskDrDave #DentalResearch

So this article came out today telling the world that red meat and cured meats are bad for you. Well too bad so sad. I love red meat. I love prosciutto. It makes me so happy. But, my love for yummy meats also makes me a hypocrite. If you have been reading my blog, you will have noticed that I do not like toxins and additives in my health products, but.....I happily eat "toxic" food? Hypocrite! Yes, I am, but I have made scientific, statistical evaluations on the risk/reward balance of meat consumption, and I am willing to accept the consequences. Let us talk about meat and cancer. The World Health Organization had 22 scientists meet at the International Agency for Research and Cancer in October of this year and published an article in The Lancet, a very reputable medical journal. All of this is VERY, VERY convincing. I mean, 22 scientists cannot be wrong! And it is The Lancet! http://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(15)00444-1/abstract But when you read the article, you see that it is basically just a review of the research that has been out there for years already. Nothing new. I bet they got together and drank some great wine, ate some awesome charcuterie and had a nice rack of lamb, while they talked about the data that their underpaid, overworked research assistants slaved over for the last 2 years. The authors quote statistics from a meta-analysis that is almost half a decade old, and if you really want to know what is going on, you have to go to the primary source, which I did. http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0020456 This article is a meta-analysis, which means that the researchers read all of the papers that they could get their hands on, set specific inclusion criteria (to make sure they evaluated only the well designed studies), and then applied statistical methods to pool the results of all the papers to obtain a net result. It is easy to get fooled by statistics, and it is even easier to take the numbers and to word them in a convincing manner. That is exactly what has happened in this situation. If we dig deeper into the numbers presented in this paper, we see a whole bunch of red flags. The authors are looking at "relative risk"; what is the risk of getting cancer in people who eat meat, in comparison to those who do not. A value of 1 means that there is no difference. A value greater than 1 means that there is an increased risk, and a value lower than one means that there is a decreased risk. Looking at some of the data in the article, we see that there is a HUGE variation in the relative risk, depending on where the reasearch was performed. In Europe the consumption of red meat was associated with a 29% increase in cancer risk, while in North America it was only 11% and in Asia it was -7%......yup, eating red meat protects you from colon cancer if you live in Asia. Just looking at those results, something is fishy! There are many other curious statistical anomolies in the paper. For example, when analysed alone, meat was protective against rectal cancer in women (-10%), so were cured meats (-6%), but when analysed together, the risk was 212% higher! Two rights make a wrong? The data is littered with all of these things that just do not add up. Then there is that whole correlation vs causation thing. The authers even admit that the research was primarily retrospective in nature, with very few interventional studies on humans existing. If we really wanted to measure the effect of meat on cancer we would have to grab a group of people who have never eaten meat, randomly assign them to a meat or non-meat group, then follow them FOREVER, and see which group had higher cancer rates. That kind of study is virtually impossible. Nonetheless, a statistical conclusion is made: eating 100 g a day of red meat is correlated to a 17% increase in colorectal cancer, and eating 50 g a day of cured meats is correlated to an 18% increase. What do these numbers mean? That is just it. Neither article gives us the key information that we need to determine the impact of these results: the baseline risk. I do not understand how articles are allowed to be published when they are speaking in terms of relative risk, when they do not tell us what the baseline risk is in the populations they studied. The impact of the results is VERY different, depending on the baseline risk. Say your base salary is $10 an hour, and eating meat increased your salary by 17%. That is an extra $1.70. Compare that to someone who makes $100 dollars an hour who gets the same 17% raise; that would be $17. I don't mean to be obvious here, but $17 is a way larger raise than $1.70. The same percent increase has a much larger effect because the baseline is higher. To truly understand the significance of these numbers, we have to look at baseline risk of colorectal cancer. What is the baseline risk of colorectal cancer in British Columbia? In 2012, the rate of new colorectal cancers was 65.35 cases per 100 000 people, making it the third most common cancer in BC. A 17% difference in the risk of cancer could make a pretty significant impact on a POPULATION level. http://www.bccancer.bc.ca/statistics-and-reports-site/Documents/Cancer_Type_Colorectal_2013.pdf Once again, however, we need to break down the numbers a little further. The incidence rate of 65.35 per 100 000 people, includes both those who overconsume meat and those who do not, and most of the cancers occur in people who are over 80 years old. That means that if we are looking at recommending the reduction of dietary meat consumption as a means of reducing the population risk of cancer, the effect is going to be less than 17% because the baseline risk includes people who are already low risk, and also includes older adults, who have increased incidences of cancer rates due to reasons other than eating red meat. The key for me is breaking down the risk to a PER PERSON level. As a British Columbian, if the incidence of colorectal cancer is 65.35 per 100 000 people, across all age groups, it means that the risk is 0.0006535% per person. Now add that 17% relative risk that was found in the study: 0.000765% per person. The real life increase in risk is negligible because the baseline risk is so low and relative risk increase is also very low. PER PERSON. The question I ask myself then is, am I willing to increase my risk of colorectal cancer from 0.0006535% to 0.000765% for the sake of eating that yummy, juicy steak on Friday after work? Or so I can pop some pancetta into my omelette on Sunday morning? Yes, yes, yes, and infinity times infinity, plus infinity yes! Meat makes me happy. Bacon is amazing. We haven't even talked about all of the benefits of eating meat. The increase in risk is so negligible on a per person level, that the true impact of eating meat on an individual's chances of getting cancer is virtually zero. Yes, if we can reduce cancer rates as a population, the world would be a better place, but the reality is that there are other places to start. Thanks for reading! Dr. Dave drdave@alfaropros.com