by Lee Ann Brady 

Have you ever noticed a confused look on the face of an older dental patient when you tell them they have a cavity? Many people falsely assume that only small children develop cavities. When I let older adults know that they have one or more cavities, they say something like, “Wait, I thought only kids get cavities” or “I haven’t had a cavity in decades.”  

They honestly think we outgrow that, so I typically say to these patients, “I know you’re thinking that cavities are something that only kids get, and you’ve outgrown this. But that isn’t accurate. Yes, kids are often prone to getting cavities, but adults can get them for the same reasons.” 

Most of my older adults with cavities are doing a good job with their oral hygiene, so I will explain four things to them.  

1. As we age our saliva is no longer as protective. There are also lots of medications older adults take that diminish saliva production. But, even if our mouth does not feel dry, the saliva does not protect us against bacteria and plaque as well as when we were younger. 
2. As we age our taste buds change, and the foods that satisfy us the most are carbohydrates, so like children, older adults tend to eat more sugary foods. 
3. As we age, if we have gum recession, we have larger space between our teeth, and this tends to trap more food particles that feed bacteria.
    
4. After teeth are restored, normal function over time can introduce openings in the restoration, and bacteria can creep into those openings. 

After we talk about the various reasons that they and other older adults may get cavities, we talk about the fact that there are several preventive strategies and I suggest ones they might like to try.  

My patients enjoy our conversations because they know I really care about them, and I will happily spend time explaining why changes are occurring in their mouth. They appreciate hearing that their problem is not unusual and there are strategies to avoid cavities going forward. 

By Paul A. Henny, DDS 

Times change; that’s for certain. When dental advertising was first allowed in the 1970’s, there was much discussion around whether marketing a dental practice was ethical. Today, marketing ethics is an issue for dental licensing boards to decide, while most dentists have moved on to focusing on HOW to best market their practice. 

Combine this new marketing-oriented mindset with the internet, and there’s a lot of confusion, wasted time, wasted money, and wasted energy. 

Why? Because most marketing efforts are focused on bodies and not people with feelings, priories and values. To quote a popular marketer in dentistry today: “In the end, the only thing that matters is how many butts you put in the chairs.” Really? And as a result, too many dentists are hung up on paying attention to the wrong metrics: ad clicks, social media likes, a high search engine results page (SERP) ranking, new patients per month, and so forth. 

It’s nice to have lots of visitors to our website (and important), but the best question to ask is: Why are prospective patients visiting our website in the first place? The answer speaks to FIT: Is this person likely to be a good fit with our practice Mission and Philosophy? 

If the person fits in with our practice’s Mission, then we’re supporting our Philosophy and moving toward our Vision. If the person doesn’t fit in with our practice’s Mission, then we aren’t. It’s that simple. 

If the person fits, they’re much more likely to schedule an appointment. If the person is a good fit, they are much more likely to be open to a proper and thorough examination process. If a person is a good fit, they’re more likely to make good decisions regarding their dental health. And if a person is a good fit, they are much more likely to agree to appropriate treatment plans. Consequently, when most people in our practice are a good “fit,” our schedule is full of folks who show up, and are grateful they found us. 

The key to successful marketing of a health-centered / relationship-based practice therefore begins BEFORE each person visits our website and therefore BEFORE they call. And that’s all related to our reputation—what’s commonly called our “brand.” Our brand is the set of expectations the person has about us. 

So, it’s important to know who they are, what they are seeking, and how we can best address it. Knowing the answers is where marketing should begin. On this, Peter Drucker famously said, “True marketing starts out with the customer, their demographics, their realities, their needs, and their values. The aim of marketing is to make selling superfluous. The aim of marketing is to know and understand the customer so well that the product or service fits him or her so well that it sells itself.” 

And that represents a whole lot more than just getting a “butt in the chair.” Mastering person-centered marketing is a key element to realizing our dream. Failing to understand it forces us to try and manage people who aren’t a good fit—sometimes multiple times a day, and that simply isn’t very fun or rewarding. 

By Steve Carstensen, DDS 

The following four exercises will support your physiology. As you practice them during the day, your nighttime breathing will improve. These exercises are not a cure for snoring or sleep apnea but any improvement in respiratory patterns helps day and night. 

Light Breathing  

Our brains are sensitive to the oxygen and carbon dioxide balance in our blood. The buildup of CO2 triggers respiratory cycles. As we breathe lightly, we increase our brain’s CO2 tolerance. If we are sensitive to hypercapnia, we breathe faster. Quicker breaths lead us into poor gas balance.  

Imagine there is a string in the top of your head pulling it towards the ceiling. Your posture is straight. Now close your lips so you are nose breathing. Breathe as lightly as you can so you barely feel the air moving through your nose for two minutes. Don’t concentrate on how deep you breathe. As you do this you will wish you could breathe a little more. That’s called “air hunger.” As you do this exercise more, the air hunger will fade. You are changing your body’s CO2 tolerance.  

Increasing the amount of CO2 our brain allows us to maintain helps our blood release more oxygen to our cells. Blowing off too much CO2 starves our cells of the oxygen they need for health.  

Deep Breathing  

The next exercise is called “Breathe Deep.” We have two different major muscle groups that fill our lungs. The primary one is the diaphragm, the secondary one is the intercostal muscles of our chest, between our ribs. Diaphragmatic breathing—breathing deep with your diaphragm, produces physiologic benefits. The increase in intra-abdominal pressure increases gut motility and activates the back and pelvic muscles to stabilize your core. This strengthens good posture.  

Sit up or stand straight. Place your hands on your sides so you feel your last two ribs. Breathe slowly and lightly. Feel those two ribs expanding. The diaphragm attaches above these ribs, so the muscles are not moving the ribs; the intra-abdominal pressure is pushing out on those ribs. Now breathe through your nose deeply so you can feel those ribs expand. Do this for two minutes. You might feel a bit of air hunger during this exercise as well.  

Slow Breathing  

The third exercise is “Breathe Slowly.” This is a cadence or timing exercise issue. As you breathe lightly and you breathe deeply, you breathe in for a count of four, hold it for a second, breathe out for a count of six, hold it for a second, and then repeat the cycle of in for four, hold for one, out for six, and hold for one. This will add up to six breaths per minute, which is the best for health because it calms the autonomic nervous system and sends the right signal to the vagus nerve and the rest of the nervous system. You can fit this into your day between patients to calm down and focus better.  

Control Pause Breathing  

The “Control Pause” breathing exercise measures the number of seconds you can comfortably hold your breath after exhaling and is an indicator of how well you breathe. Athletes can go as long as 40 seconds. You might be able to go 15, and that’s okay because this exercise, practiced over time, will improve your breathing volume.  

Breathe in through your nose, exhale, and then pinch your nose. Wait for your body to tell you when to breathe. This is not the very first indication, nor is it a ‘breath-holding contest.’  When you are aware of the signal, breathe normally again for ten seconds, pinch your nose again, and hold. By practicing this pattern for three minutes, over time, you will see you can pause your breathing longer and longer. The number doesn’t matter. The effect you have on the number with practice does matter. If you aim towards a pause of 30 to 40 seconds, you can achieve great breathing health and athletic fitness. It’s another way of increasing your CO2 tolerance, providing more oxygen to your cells.  

By Paul A. Henny, DDS 

The Case for Setting Boundaries 

When we are financially or emotionally dependent on patients saying “yes,” we crave acceptance which comes at cost: we are fearful of offending the person if we say, suggest, or do something that might trigger a “no,”—so we strategically modify our behavior to avoid rejection. 

On the other hand, independence allows us to adopt a course of action—a purpose that’s clearly justified in our mind, and accepting of the fact that some people might disagree and therefore their opinions will not influence how we feel about ourselves. So, independence involves respecting how others feel AND how we feel—a critical issue that’s known as psychological boundary. 

What’s Our Goal? 

Our goal should be to help others as much as possible—but not to manipulate them into making decisions or taking actions they would otherwise not make. If we feel like we cannot help someone, or if we believe helping a person in the way they are demanding is harmful long-term, then we simply need to find a way to respectfully agree-to-disagree, and move on. No need for moralistic stands. No need for judgment. We just need to continue our search for others who are in closer alignment with our purpose. 

As we become masterful at the execution of our purpose, we become known for it —we become “branded.” Once branded, more like-minded people can find us in the sea of other options and then make a higher level decision than “he/she is in my network.”  

Start with Personal Leadership 

Relationship-based, health-centered dentistry therefore starts with personal leadership and personal power. Who am I? What am I willing to stand for? What am I willing to share with the world? What am I unabashedly willing to promote because I believe in its value so deeply that I simply must promote it. And critically, HOW can I best promote it so that more people will be able to make better decisions for themselves that are more in alignment with our purpose, and that move them closer to an optimized health? 

“Know Thyself,” the ancient Greek appeal to greater self-awareness, is one of the four principles incorporated into L. D. Pankey’s “Cross of Dentistry.” But following this sage advice isn’t easy, as we’re pulled and pushed around by the environment; we’re constantly challenged to either adapt, resist, surrender or lead. 

Being Authentic Requires Regular Introspection 

Leading is only possible in patient-centered dentistry through authenticity—through clarified values aligned with a congruent vision and ACTION. Hence, without self-awareness, the seductions of life—the temptation to take shortcuts, and the trappings of materialism, can easily lead us away from our authentic self. What makes this process even more challenging is that when we feel threatened or rejected, we tend to do more of those things while blocking out how we truly feel. We lose ourselves in our pursuit of things that we think will sooth our anxiety.  

Gaining greater self-awareness through regular introspection is the starting point of a process that essentially never ends, but it represents the only pathway toward authentic leadership. Authentic leadership is an inside-out process that’s at the very core of patient-centered dentistry, which is why Dr. Pankey inscribed “happiness” as the outcome of his developmental philosophy. 

By Steve Carstensen, DDS 

Patients come to our dental offices with some common complaints related to poor breathing and oral inflammation…dry mouth…bad breath…gingivitis…excessive wear on teeth. They ask us to help them.  

One of the things we can do for our patients is to be curious about whether they have intermittent hypoxemia that is diagnosable and treatable. I caution us to be aware of having too narrow of a focus. When someone presents with jaw pain, wake-up headaches, and tooth wear, we tend to think they need a supporting nightguard. I think we should be curious about what else might be going on. 

I ask my patients about snoring. I ask them if they have been diagnosed with a breathing disorder. I wonder if they should be using CPAP before I make a bite splint. If you make a splint, they may come back and report they don’t like the splint, which may be because it interferes with their breathing. So, I recommend we stay curious, and when we do make a protective guard for their teeth, we ask more questions. Make sure the diagnosis we make not only correlates with the symptoms, but the patient responds well to the treatment we provide.  

How can we help our patients’ breathing physiology? We can help them be better breathers. There are oral appliances that keep the jaw from falling back and crowding the airway but what about the daytime? It turns out that people who breathe “badly” during the day develop breathing behaviors that the brain continues during the night, and these behaviors are inefficient for keeping the airway open during sleep. So, if we help our patients breathe better in the daytime, we set their brains to be more capable of handling airway disruptions during sleep.  

If you’ve read the book Breath by James Nestor, you will learn about the daytime problems translating into nighttime problems and that nose breathing is best for our physiology. I am a huge nose breathing fan. There are electrical signals that pass from specialized cells in the nose directly to the limbic system which influences our autonomic nervous system. It filters sensory signals from the rest of the body and sends proprioceptive signals into the cortex and down into the autonomic nervous system. None of these brain-signaling signals happen with mouth breathing. 

If you ask someone, “How is your nose breathing?” They will say, “Fine,” because you are the dentist, and they think that is a strange question. They also are accustomed to the amount of work it takes to breathe through their nose, so they don’t really know if they breathe through their nose well enough. The way to test is to ask them to close their lips and put their finger over their lips for two minutes and breathe calmly. With the finger over their lips, they are unlikely to have difficulty breathing through their nose but if they start breathing faster this is a sign of stress. If their heart rate goes up, if they know it was tough for them to do, there is something interfering with their nose breathing. It might be a deviated septum, allergies, a head cold or chronic rhinitis—but something is wrong.  

Knowing this is handy when we are planning to do restorations. You won’t use a rubber dam if they can’t breathe through their nose, or you will schedule to do the restorations after they’ve been medicated. I have found that Afrin is good for clearing the nasal passages before dental treatments. Short-term help is good but stay curious about how often they cannot breathe through their nose, and help them. 

By Paul A. Henny, DDS 

The word “prescriptive” recently got stuck in my head. It made me think about the important distinction between a relationship that’s primarily focused around “giving directions or injunctions” versus mutually goal-oriented and collaborative. It’s all too easy in the middle of a busy day to reduce our patients’ complex problems down to prescriptive responses so we can move on to the next problem or obligation on our schedule.  

The reality of dentistry was brilliantly stated long ago by Bob Barkley, “Our goal is to design dentistry that will fail at the slowest possible rate.” This humble statement should always sit at the center of our practice philosophy: We aren’t gods; hence we aren’t perfect, and we can’t control the future. The best we can do is learn, practice, and do our best with the best of intentions. The rest will be up to the patient and fate.  

If our patients choose to not assertively take charge of their oral microbiome through appropriate oral hygiene and diet management, then all of our skills and good intentions will be undercut, and the failures sometimes blame-shifted onto us. That thought brings me around to the central reason behind why I’m writing today: We can’t be successful unless we are also good teachers and leaders. We have to want our patients to be successful on a very deep level. 

Last year my daughter Allison graduated at the top of her high school class, and it was easy to think “Wow! Look at what she did!” Yet it wasn’t just her efforts that made it happen, so the thought should be “Wow! Look at what WE did!” as the effort was communal and very philosophically-driven. It’s clear that Allison’s Principal and teachers LOVED her enough to invest a significant part of themselves in her development. You could feel it, see it, and hear it in their words. 

Are we similarly invested in our patients success? Are we doing a whole lot more than just being prescriptive? Are we investing a significant part of ourselves in our patients’ lives because we want to see them succeed? Can they feel it, see it, and hear it?  

By Steve Carstensen, DDS 

I want to share a clear example of how bad sleep directly affects the anatomical structures dentists pay a lot of attention to—the mandibular condyles.  

Sleep Disruption Disrupts Bone Regeneration 

We’ve all seen on X-rays condyles that do not look healthy. We wonder what causes so much degeneration. There are shelves of books and whole courses about what goes wrong but one of the things that affects condyles is a circadian rhythm disruption. Research* with rats has demonstrated that sleep disruption disrupts bone regeneration, causing thinning of the condyles. 

* Corrigendum: Circadian rhythm protein Bmal1 modulates cartilage gene expression in temporomandibular joint osteoarthritis via the MAPK/ERK pathway. Chen G, Zhao H, Ma S, Chen L, Wu G, Zhu Y, Zhu J, Ma C, Zhao H.Front Pharmacol. 2022 Sep 8;13:971840. doi: 10.3389/fphar.2022.971840. eCollection 2022.  

Rats were interrupted from their sleep cycles so they could not get through a normal night’s sleep. After eight weeks they took the disruptions away. During the first four weeks the cartilage layer over the condyles thinned, became really thin at six weeks, and stayed that way across eight weeks. After they returned the rats to undisrupted sleep for four weeks, the breaks in the normal covering of the condyles were still there.  

What do we take from that? The earlier in life that we establish healthy physiology that supports healthy sleep, the greater the chance children have of growing human condyles to withstand TMJ problems later.  

Disrupted Sleep Contributes to Multiple Health Issues 

There’s a lot of research that points to poor breathing contributing to pediatric and adolescent health issues. Among these issues are neurological deficits, behavioral problems, poor school performance, and pulmonary hypertension. A primary cause of poor-quality sleep among our youngest patients is enlarged tonsils and adenoids that obstruct their airway.  

Helping Children and Teens Breath and Sleep Better 

What can dentists do in daily practice with children and teens to help them breathe better and sleep better early in life?  

1. Educate our adult patients who are parents of children to be aware of signs and symptoms.  
2. Develop a culture within our practice of being a health consultant, so our adult patients feel welcome to easily engage in conversations about health issues that commonly affect children and teens.  
3. Introduce the parents to their own need for an open airway for healthy sleep to raise awareness.  
4. Assess all our patients for breathing issues and examine their airways for signs of obstruction.  
5. Provide guidance to our adult patients and to the parents of the young people in our care so they can choose appropriate care.  

Our Responsibility 

We need to start paying attention to these things as much as we do the health of the teeth and periodontium. As dentists, we are responsible for the entire cranial facial respiratory complex. My colleague, Dr. Kevin Boyd in Chicago, is a pediatric dentist who came up with that label a few years ago. I love that term, because it helps us focus on the whole person, structure and function! We can be proud when we help our patients with the respiratory part of the complex. 

As we take our place in medicine as being in charge of the cranial facial respiratory complex, we get to affect growth and development. We get to help train the body to swallow properly and grow good bone and good airway support. And that’s the major role I think dentists are going to have going forward in healthcare–identifying those children who have an underdeveloped cranial facial respiratory complex and influencing their care. Like other folks in medicine…an ENT doctor…a myofunctional therapist…a speech therapist, we help correct the things that we recognize that are going wrong.