Happiness for me in dentistry was always doing my best for patients who appreciated and wanted the best dentistry. When third parties began to heavily impact the care patients wanted and my ability to do my best, my happiness disappeared, and burnout set it.

Independence to me meant removing myself and leading my patients away from insurance dependence. The Pankey Institute showed me the way to do this, and I was able to start restoring my happiness one patient at a time, until I was finally once again “fee for service.” Whether you can do this in part or in whole, you will achieve more dentistry and have a greater impact on more lives.

I first attended The Pankey Institute in the late eighties. I was at the lowest point of my career. Admittedly times were a bit easier for a young dentist back then, but in many fundamental ways they were the same. On the first morning at the Institute, I remember feeling overwhelmed. I was focused on the herculean task of creating the practice of my dreams. Every moment of that first week tested my competence and potential to succeed. I kept comparing myself with other students as I paid attention and diligently took notes.

Later in the week, Dr. Irwin Becker was discussing how to schedule patients so we would have time to practice what we were learning. I returned home and secured every Thursday morning for practicing “the Pankey way” which included a lot of new techniques for me and my staff. Dr. Becker was more correct than he even knew when he recommended that we “just do it.”

The Science of Motivation

About the same time, during the eighties, two psychologists, Edward Deci and Richard Ryan from the University of Rochester were beginning to formulate their now groundbreaking Self Determination Theory of Human Motivation. Their advice also came down to “Just Do It.” Years later, while studying positive psychology, I was gratified that I took Dr. Becker’s advice; otherwise I may not have had an accomplished and fulfilling career.

Deci and Ryan defined motivation as the “energy required for action.” How many times do we attempt to accomplish a worthy goal but run out of steam? We need drive. Installing a fee-for-service practice is difficult…if we dare to do it. It requires resources like drive and energy.

Deci and Ryan noted extrinsic drives are the material rewards we are all familiar with, as well as status and recognition. The intrinsic drives are passion, curiosity, and purpose. They found intrinsic motivation is more effective in every tested situation, except when basic needs haven’t been met (think Maslow’s Hierarchy of Needs). They also found that autonomous work overrides controlled work because autonomy is aligned with our intrinsic drives.

Autonomy as an Intrinsic Driver Works

When we are the masters of our own destiny, we are also more focused, productive, optimistic, resilient, creative, and healthy. In retrospect, this is what I found on those Thursday mornings. When I was focused on doing a comprehensive, relationship-based new patient exam, to the best of my ability and focused on leading the special person before me to greater understanding and health without thoughts about personal gain… putting another first and giving them the gift of my time… I felt most alive and well myself.

I started with the comprehensive examination and built on that by learning all the components from the mundane mounting of models to the nuances of advanced occlusion. For those of you starting to implement a fee-for-service practice model, success can be measured one morning a week and one patient at a time. Your intrinsic motivation will carry you forward to expand your “Pankey style” approach to a greater and greater percentage of your patients.

Beyond Scheduling One Special Morning…Return to “The Porch”

My latest book, The Porch: A Dental Fable, tells the story of a young dentist who is led in mentoring relationship — by a retired dentist and an expanding group of encouraging colleagues who meet regularly on a porch. He discovers and practices a new philosophical and behavioral approach to practice that transforms his life. I’ll keep blogging on this theme, but between blogs, you might want to pick up the book and discover the richness of a life in dentistry based on intrinsic drive. If you have sampled The Pankey Institute offerings and been inspired, then stay on “the porch” of its philosophical approach, courses, study clubs, and collegial gatherings. Continuously sharing and supporting one another is what put me on the never-ending, meaningful, highly satisfying Road of Mastery…and never again to experience burnout.

This blog is a precursor for the long lecture I will do on this topic at the 2021 Pankey Symposium.

Over the last decade, there have been major changes in how we do things in our laboratory (Niche Dental Studio), but from small cases to full mouth and hybrid cases, traditional Prosthodontic protocols still guide everything we do. These foundational processes provide a structural/philosophical approach for all our cases.

It’s a philosophical approach to diagnosis and treatment that you have been learning in your Pankey Institute courses. It’s an approach that extends from your dental practice into our lab, so our lab becomes part of your practice.

What are the key principles of this philosophy or approach?

• We will use optimal diagnostic protocols, communication, technology and methods to deliver custom prostheses as efficiently as possible while not compromising on the quality of the products.
• We will do our best to deliver products that meet or exceed your expectations for optimal function, comfort, and natural esthetics.

Here are some of the things that we do the same and some we do differently than we did ten years ago.

Feldspathic ceramics still produce the most natural appearance.

In the past everything we made was made by hand, and it was the prosthodontic protocols of this handwork that enabled us to have success using CADCAM technology today. And while today’s CADCAM dentistry is great, it does not replicate the results of restorations made by hand. A machine can’t mill “infinity margins.” Monolithic materials used in milling do not contain multiple levels of opacity.

To blend perfectly with Nature, restorations must still be made by hand, and in our laboratory, feldspathic veneers are still our “go to” type of restoration for central incisors. Layered feldspathic ceramics not only look the best but also are the best for marginal integrity. The restoration on number 8 below is an example.

For fit and finish, these types of anterior restorations are still the prosthodontic foundation of our Niche Dental Studio.

We still aim to replicate natural teeth.

Another foundational attribute of prosthodontic protocols is to replicate nature. Part of our success has been how much time and effort we have put into studying natural teeth and helping Pankey Institute trained dentists distinguish themselves by using restorations that are exquisitely made to appear natural and blend in the patient’s smile.

Today’s patients desire natural esthetics once they understand the elements of what makes teeth appear natural. If a patient seems stuck on a cosmetic dentistry meme of the past and requests whiter, brighter, straight teeth that will not blend in their smile, a conversation with your patient that illustrates tooth, smile, and facial esthetics will be appreciated by your patient and distinguish you as a caring, exacting dentist.

To create restorations that appear natural and don’t “jump out,” we do the following things:

• Increase the “value” of the color but not enough to create harsh contrast.
• Play with the levels of the incisal embrasures and the translucency.

These prosthodontic protocols can be implemented by you, too, while doing composite build-ups.

We use new technology to optimize communication.

From the ceramist’s perspective, I don’t want to see just close-up images of teeth. I want to see the patient. For many of our cases, we see the patient in our lab. Local patients come in for a consultation. We consult with other patients via Skype or Facetime. Seeing the entire smile, the entire face in natural interaction, aids us in doing our best.

 Modern 3D technology has changed how labs communicate visually with doctors and their patients. We’re constantly sending 3D screen shots back and forth with our doctors so they can check out the design and show them to a patient. An image like this one is confusing to patients. So, we’ve been able to integrate those screen shots into a photo of the patient to create a virtual image the patient grasps more easily.

CAD technology allows us to work more efficiently, but we still hand-finish restorations.

In our laboratory, we mill a lot of lithium disilicate crowns for clients. Prior to milling the lithium disilicate, we like to mill the restorations in wax. The milling quickly does 80% of the model creation and gives us the opportunity to hand finish the other 20% as we traditionally would. We can now put all our esthetic and creative efforts into finishing the case. We also mill temporary restorations from IOS data without hand modifying them.

Using IOS and CAD has made the lives of our clients much easier. For example, in the past, with full mouth cases, we did a lot of wax-ups when raising verticals. The doctors found working with matrixes too time consuming. They preferred working with eggshells and would reline them. Little problems would creep in when seating these eggshells. Perhaps, the cant was a little off or the vertical wasn’t raised accurately. With 3D imaging, it is far easier, because now we can do our full mouth wax-ups, scan them, and print the eggshells from scans with full palatal rest and retro-molar rest. There is now only one definitive way to seat the eggshells.

This is just a taste. There is so much to share.

To see how we do actual cases, in detail, go to the free Pankey Webinar: Prosthodontic Protocols for the Modern Dental Team. There you will see how our modernized approach, guided by traditional prosthodontic processes, becomes an extension of your treatment goals. I look forward to sharing more with you at the 2021 Pankey Symposium.

I was at the Ontario Dental Society meeting giving a presentation on occlusion, and I was asked one of the most common questions I receive when discussing anterior-only appliances: “What about tooth movement, either eruption or intrusion? Isn’t that a risk with these devices?” The answer is, yes there are risks, as with everything we do. Let’s consider the risks and how we can minimize and avoid them.

There are many types of anterior-only appliances, temporary and long term. Popular temporary anterior bite splint appliances are QuickSplint® and the Best-Bite™ Discluder from WhipMix®. NTI-tss Plus™ from NDX® National Dentex Labs is designed as a permanent anterior only and then there are the Kois Deprogrammer, Spear style deprogrammer, Lucia jigs, regular deprogrammers, Dawson B-Splints and so on. They are designed so that when the patient bites in MIP, they only touch on the front. When the patient goes into any excursive position (right, left, forward or back), they can only touch in the anterior—plastic to plastic or teeth to plastic.

We love anterior-only appliances because of their efficiency and effectiveness in eliminating posterior contact and allowing TMJ muscles to optimally relax. But we do worry about tooth movement, so how do we evaluate the risk and how do we minimize it?

There are a couple of pieces to this puzzle. We know that super eruption of the back teeth may occur if the appliance is worn more than ten hours a day, consistently over many days, even weeks, in a row. This means the risk is minimal with nighttime wear only for eight hours a night. Since we do not want patients to wear these types of appliances 24 hours a day, a patient in acute pain might be best helped with an anterior-only appliance for nighttime and a different type of appliance for daytime.

There is also a risk of lower tooth intrusion. There are two ways to deal with that. One is to make sure they have contact from canine to canine to distribute forces. Another is to make the upper anterior discluder against an appliance on the bottom that is called “a slider.” This is essentially a thicker version of an Essix retainer on the bottom to distribute the forces. I have made these appliances for many years and have not observed a problem in my own practice. I had one patient with significant deprogramming who could only touch on her first point of contact, but that was not due to tooth movement. It was because of total elimination of her masticatory muscle memory.

If you are concerned about tooth movement, I recommend making the upper discluder on a full arch Essix and then put the patient in a full arch lower Essix (lower slider) that will distribute the forces. That will prevent the problem of super eruption and should significantly minimize potential for intrusion, even though you only have midpoint contact. This is a great way to moderate the risks of tooth movement for patients who are going to wear an anterior-only appliance long term.

I would like to add, that any time you put a patient on appliance therapy, you need to see them for post-op appointments. You need to verify the appliance is working—that their signs and symptoms are going away or minimizing. And, you need to check their occlusion and mandibular position. So, I always plan multiple follow up appointments and include those in the appliance therapy fee. Even when the patient and I think everything is going great and they are wearing their appliance only at night long term, I ask them to bring their appliance to every Hygiene appointment for professional cleaning. This reminds us to ask how things are going with their appliance and gives me the opportunity to check their occlusion and make sure there are no negative consequences of the therapy. I also tell my patients to call if they notice any change in their bite. “We need to have you come in and check that right away.”

One of the greatest challenges of dentistry is developing a conceptual framework for how to approach complex cases. We leave dental school bright-eyed but unfamiliar with the personal and professional tools that help us get to know patient needs and provide optimal care over a lifetime.

Phased therapy is a skill that takes time to develop but creates the mental space to build relationships and techniques simultaneously. How do you follow through on a treatment plan over the course of many years, phasing out the process to improve the patient’s experience, your experience, and their ability to afford it?

Single tooth dentistry may seem simpler than a full mouth reconstruction, but it still poses its own set of challenges. You’ll be able to gain skills without requiring patients to commit to a heavy financial burden, but you’ll still need to manage esthetics and deal with unforeseen issues with occlusion.
A dental career is one marked by introspection that necessarily leads to improved patient care as you gain greater self-knowledge alongside technical skills. Here are 2 tips you can use to develop your love of both simple and complex cases, your long-term relationships with patients, and your passion for dentistry:

1. Approach Learning as a Layered Process

It’s easy to get hung up on technical prowess and let your communication skills or personal development suffer. The mountain of knowledge that exists in dentistry is formidable, especially the way it is presented early on in our dental educations.

But you don’t have to build Rome in a day. Start with single tooth dentistry so that you have time to learn the technical and behavior skills along the way that will build your confidence to tackle bigger cases.
Longevity in a career as physically and emotionally demanding as dentistry requires that we approach learning as a layered process. Each case deepens our understanding of how to evaluate and succeed at the next one. Along the way, we can find joy in each incremental improvement.

2. Build Trust Through Patience and Demonstrable Success

Nothing works without the patient’s trust and acceptance. They will be more likely to say yes to a simpler restorative case. What you’ll find is that as they get to know you and you get to know them, their willingness to engage in future dentistry will improve.

With patience, you’ll put in the work to improve their health and esthetics. The fruits of your labor will naturally result in greater trust.

Later this year, I’ll be hosting my course “Think Global, Work Local,” at Pankey Online. During this course, I’ll dive deeper into the concepts I’ve brought up here.

I’ll be covering three cases that stood out in my career, including the details on preparations, impressions, fee presentation, treatment planning, restorative care, and case results.

I can’t wait to see you there for this opportunity to dive into a Pankey-infused approach to learning over a lifetime!

In a previous blog, I wrote about how we use multiple flavors of topical in my dental practice and the positive patient experience this creates. In this article, we will look at the topical application technique we use to create maximum patient comfort.

I have often debated in my mind whether topical actually makes patients feel more comfortable when anesthetic will be injected. The scientific literature confirms it works great on the surface of mucosa, but it does not reach nerves under the gums or in teeth. From working with my patients, I know it makes a difference to them in how they perceive the injection feels. And there are studies in which patients overwhelmingly self-report that the initial pinch feeling of the needle entering the tissue is reduced after topical.

Before applying topical, thoroughly dry the area so the topical goes directly on the tissue you want to numb. If topical is applied to saliva, its effectiveness is greatly reduced. Ideally, let the topical work for 60 seconds but minimally 30 seconds prior to beginning the injection. My technique is to thoroughly dry the mucosa, swab the dry area with topical, leave the cotton tip applicator in place against the mucosa, cover it with a 2×2, and have the patient close to hold it in place while I watch the clock for 60 seconds to make sure I am not rushing.

To deliver anesthetic I use The Wand computer-assisted anesthetic delivery technology. While I am waiting for the 60 seconds, I explain to the patient that the anesthetic delivery may be different than they have experienced before and how the anesthetic will be delivered.

In my last blog, I wrote about the value of offering patients a choice of topical flavors. I can also fill some of the 60 seconds by asking the patient if the topical administered tastes like the flavor of topical they selected. As soon as the 60 seconds have passed, I immediately remove the 2×2 and cotton tip applicator and begin delivering the anesthetic.

There is good science behind some types of topical acting faster than 60 seconds, so you may want to do some research and select one of these types.

Even if you think topical is not effective, think about the placebo effect topical has on the patient. We are doing something to improve their comfort. We are actively doing something to make the procedure more comfortable and to help them through the process. I believe this act of caring has value to the patient that even exceeds the value of the numbing effectiveness reported in clinical trials.

Cannabidiol, commonly known as CBD, is getting significant attention in new advances of pain management for its non-psychoactive therapeutic properties. Topical CBD oil has been suggested as a way to non-invasively treat pain caused by temporomandibular disorders. But does the science currently support CBD oil or even prove its efficacy versus a placebo?
CBD smoothies, CBD cream, CBD bath bombs… the consumer market is flooded with a variety of premium products touting everything from anxiety reduction to chronic pain treatment. If you haven’t been asked for your medical opinion about CBD yet, you may be soon.

Topical CBD oil is expensive and trendy. Roll-on applicators are often combined with other active ingredients like menthol and arnica to soothe the symptoms of pain. Roll-on CBD may be infused with essential oils, so it even has a therapeutic aroma. With attractive green packaging and clever names to boot, the purchase can be a no-brainer for those suffering from aches and tension in their jaw.

Evidence-based dentistry demands a suspicious eye. Is all this external dressing, pleasant smells, and clever marketing covering up a dearth of clinical evidence? Let’s take a dive into the science:

What CBD Is and What CBD Isn’t

Cannabidiol has come to prominence as the safer alternative to tetrahydrocannabinol (THC). Evidence has shown it may be effective in the treatment of childhood epilepsy.¹ There is even an FDA-approved CBD-based treatment, Epidiolex, for two severe forms of epilepsy.²

Besides this specific use in the management of epileptic seizures, CBD is sold as a supplement.¹ The number one issue here is the lack of regulation over supplements. You can’t be certain that the amount of CBD stated on the label corresponds to the actual levels in the formulation.¹ Even more concerning, there is no widely accepted, clinical trial approved therapeutic topical or oral dose of CBD designated for the management of chronic pain.¹ Can a treatment be ethically recommended when there is no consensus on effective, safe dose?

Unlike THC, CBD does not cause a high. But it can have side effects such as nausea or even impact the level of medications in the blood.¹ We know very little about the effects of cannabidiol in the context of large sample size human clinical trials. How long should a patient apply CBD for? At what dose should they apply it? How regularly? The answers to these questions are not currently known.

CBD and TMD: Friend, Foe, or Placebo?

A 2020 systematic review with meta-analysis of topical intervention efficacy for temporomandibular disorders compared the current data on treatments such as nonsteroidal anti-inflammatories (NSAIDs), cannabidiol, capsaicin, bee venom, and more.³ Topical therapies are especially attractive because of the serious consequences to long-term oral NSAID use for TMDs.³

Topical doses of a drug or therapeutic can bypass the debilitating side-effects of systemic treatment.³ Topical NSAIDs include diclofenac sodium and methyl salicylate.3 Therapies like bee venom and CBD are called “nutraceuticals,” which refers broadly to food-derived alternatives to pharmaceuticals, usually sold as supplements.³

The 2020 review was only able to find 9 studies regarding topical treatment of TMDs that met rigorous criteria for quality of evidence while also qualifying as randomized controlled trials.³ For topical NSAIDs, the review found no clinically significant difference compared to a placebo.³ Interestingly, ultrasound therapy was found to reduce pain, but applying an NSAID gel with ultrasound had no statistically significant difference compared to ultrasound without the gel.³

The effect of bee venom and capsaicin was similarly inscrutable, with few relevant studies including the proper data values or standard deviations to conduct a meta-analysis.³ The evidence in general was low quality or showed little effect.³

CBD also suffered from a lack of high-quality evidence in the form of studies in humans.³ Animal models have shown that “transdermal cannabinoids” may reduce pain and inflammation, but there is currently no clear evidence for long-term benefits in humans.³

Why is the research for topical treatment of TMD-associated pain so poor? The answer is small sample sizes, poor blinding, and unreported funding sources.³ Because of this, we don’t know whether demonstrated effects, if any, apply to a larger population.

Statistics have less meaning in small sample sizes. Poor blinding means that bias cannot be controlled. Lack of clear funding disclosures may also influence blinding and make it difficult to trust whether research was conducted in good faith.

The Future of CBD in Dentistry

Though data regarding CBD for TMDs is severely lacking, the future may offer some hope. If motivated researchers feel passionately about reducing the burden of chronic pain for sufferers of temporomandibular disorders, they may be able to put forward the time, money, and effort necessary to distinguish the minimum safe yet therapeutic dose of CBD.

They will also have to determine its ideal application parameters and any necessary or helpful active ingredients. They’ll need large numbers of study participants, including hundreds of individuals for control and experimental groups, and a well-considered experimental design.
That outcome may take many years. In the meantime, topical CBD will remain the equivalent of a high-end massage oil.

References:

1. MD PG. Cannabidiol (CBD) — what we know and what we don’t. Harvard Health Blog. Published August 24, 2018. https://www.health.harvard.edu/blog/cannabidiol-cbd-what-we-know-and-what-we-dont-2018082414476
2. FDA Approves First Drug Comprised of an Active Ingredient Derived from Marijuana to Treat Rare, Severe Forms of Epilepsy. FDA. Published March 27, 2020. https://www.fda.gov/news-events/press-announcements/fda-approves-first-drug-comprised-active-ingredient-derived-marijuana-treat-rare-severe-forms
3. Mena M, Dalbah L, Levi L, Padilla M, Enciso R. Efficacy of topical interventions for temporomandibular disorders compared to placebo or control therapy: a systematic review with meta-analysis. J Dent Anesth Pain Med. 2020;20(6):337-356. doi:17245/jdapm.2020.20.6.337

Despite headlines you may have read, heart disease is still the number one killer in the U.S., followed by cancer and then (hopefully only temporarily) COVID-19. Gum disease is on the rise in this country. This condition affects much more than just a person’s mouth. We need to shut down the dangerous anaerobes that live in our tissue and bone that drive the oral and systemic inflammation. The bacteria that live in our mouth do not stay in our mouth! Hygienists are not only cleaning deposits off of teeth; they are managing dangerous bacteria and saving lives!

Patients see their dentist more often than they see their physician. The start to providing optimal care is having informative conversations with our patients when discussing their health history, their medications, and the tie in their periodontal and endodontic health.

Married to a cardiologist, it was beneficial for both my dental patients and his medical patients to receive integrative care, and to that end, we worked together to build a center for my restorative practice that includes oral-systemic health diagnostics, counseling, and treatment.

Pushing the Standard of Care

My practice, Complete Heath Dentistry of Columbus, is distinguished from other practices by pushing the standard of care to treat patients based on his or her risk factors for developing systemic health issues. Saliva/oral DNA testing enables us to take this proactive health approach. This testing allows us to learn if our patients have dangerous oral pathogens. It helps guide us on how to better treat our dental patients with periodontal therapy and with oral probiotics, as well as Perio Protect trays.

My husband, Dr. Eric Goulder, and I opened the first medical center in the United States with an accredited Cardiologist and Dentist to practice the Bale Doneen Method testing and care under one roof. We passionately believe a medical Bale Doneen provider cannot optimally help their patient without the assistance of a dental team that understands the value of their work.

With every patient, we discuss oral health risk factors for cardiovascular disease and strokes. We use saliva/oral DNA testing to proactively calculate the CVD risks of our patients with the recommendation they create a health plan with their doctor geared toward overall health. With focus on prevention and the elimination of disease, we work with patients to achieve optimal oral and systemic health.

Pushing Dental-Medical Integration

Across the country, dentists are teaming with cardiologists to better understand the oral-systemic connection and to help their patients discover developing risk factors for heart attack and stroke, among other diseases such as diabetes. You do not have to have a cardiologist under your roof to similarly help your patients.

You can explain to your patients that one of the most painless tests that can reveal hidden heart attack or stroke risks is a carotid artery scan (CIMT scan) that measures carotid intima-media thickness. It is an important test for individuals with few risk factors for developing cardiovascular issues. Under traditional care, 75 percent of heart attacks happen in people with normal cholesterol levels. Through this no radiation ultrasound procedure, the neck is examined so that a doctor can uncover whether or not a patient is heading for health problems. This screening detects atherosclerosis, a condition where deposits hide within the arteries. Also, it is possible to find the “age” of a patient’s arteries.

Through CIMT ultrasound testing, a cardiovascular problem can be identified 10-15 years prior to an event. While 50% of the population does not know they have a growing cardiovascular problem, this simple test provides an early diagnosis for lifestyle counseling and dental-medical treatment.

Working with your patients and their physicians, you can also recommend the NT-ProBNP blood test that is a part of the blood testing involved with the Bale Doneen Method. This test measures the amount of BNP in the blood.  When the heart is under stress, the body excretes high levels of this substance. If elevated levels are detected, it is a red flag that a person may be heading for a stroke or heart attack.

Dr. Eric Goulder and I are on a mission to push physicians to be proactive, to understand what is going on inside arteries, discover why the disease is present, and observe the disease stabilize after treatment. I encourage you to become familiar with the Bale Doneen Method if you have not already done so and become familiar with cardiologists in your area who can be of assistance to your patients. Two-way referrals are a natural outcome of developing these relationships, and patients are very appreciative.

Key Points:
• Platelet-Rich Plasma (PRP) is not FDA approved. It is an “off-label” therapy.
• PRP is considered safe.
• There is no standardization of PRP treatments, making it difficult to determine how it heals or encourages healing.

If you regularly work with an oral surgeon, you’ve probably heard the term Platelet-Rich Plasma or “PRP.” Put simply, PRP is a technique where blood is drawn from a patient and spun in a centrifuge to produce a clot composed of the patient’s own platelets. This clot is then placed into a wound or surgical site to stem the flow of blood and promote healing. In short, a clinician removes the red blood cells from whole blood.

PRP is an autologous cell therapy. This just means that cells are used on the same patient they came from.

What is PRP and How is it Regulated?

PRP is a relatively simple procedure that is favored in clinical practice due to its safety and perceived efficacy. Because it is drawn from a patient’s own blood and is similar to a previously cleared therapeutic, it has so far bypassed the lengthy and expensive process of FDA approval for biologics.¹ PRP is not FDA approved, though it is cleared legally for specific therapeutic uses, and therefore guidelines must be followed to adhere to FDA regulations.¹

A 2018 review of the economics and regulatory outcomes for PRP describes the treatment’s 5-to-10-year outlook as enormous, citing “between 380 million and 4.5 billion (USD)” in growth.¹ Procedures may start at a minimum of $500 and can be thousands of dollars.¹

What this means in short is that PRP is an expensive treatment lacking in proven clinical trial data and is not paid for by insurance.¹ This may not sound like a promising description, but it doesn’t mean the treatment is ineffective or not worth the money depending on its application.

PRP is regulated based on certain qualities of how it is collected from the patient and the number of platelets per volume.¹ It often contains a unique combination of leukocytes (immune cells/white blood cells), platelets (cell fragments without a nucleus), and fibrin (fibrous protein necessary for clotting).¹

Why Clinical Trial Data is Limited for PRP

The large variation in techniques used for the collection of PRP, as well as inherent differences in composition that can be attributed to individual patient differences, make it supremely difficult to study the efficacy of the treatment.¹ It also makes it very challenging to compare different treatment styles. It is complicated to design a study with the necessary “statistical power” to draw a valid conclusion from the data. This is true of many biologics or stem-cell based therapies. How do you determine that the effect you are witnessing is truly a result of the cell-based therapy? Moreover, what part of the therapy is generating the effect? Cells are unpredictable.

In order to study the effect of PRP therapeutically, it would be necessary for multiple studies with large sample sizes to use the exact same materials and experimental conditions, all the way down to the exact collecting tube and centrifugation speed.¹ Clear and replicable methodology (the exact steps taken, in what order, with what materials, and for what duration) is often missing in scientific literature due to fears over proprietary information or lack of thorough reporting.

PRP is a Mixture of Many Different Therapeutic Substances

When trying to understand or tease out how PRP effects the surrounding tissue, it’s helpful to think of the clot as an intentionally overcooked minestrone. This soupy, gelatinous mixture was made by a brilliant chef with a few screws loose. We know there are tomatoes and carrots and potatoes, with some vegetable broth and a bit of salt, but some of the ingredients are difficult to identify. Did she throw in a dash of dill? Is it the pepper that’s leaving such a strong aftertaste? Does the minestrone taste good mainly because of the tomato? The tomato is everywhere, so it’s easy to differentiate. But that can’t possibly be the entire picture contributing to such a delicious soup du jour.

PRP is infinitely more complicated than a well-made minestrone. It contains growth factors, AKA a protein or hormone that regulates cell behavior, such as proliferation or healing.¹ But it also contains the immune cells mentioned earlier. And ions. And many other molecules and proteins with diverse purposes in the body. It’s hard to offer a therapy to someone if you don’t fully understand why it works. You know the soup is tasty, but what about this exact combination of ingredients is making it better than the one you make at home from a can?

So far, PRP has been deemed relatively safe.¹ It is considered an “off-label” treatment that was cleared, but not approved, by the FDA under the 510(k) substantial equivalency pathway.¹ This pathway allows transplanted human tissue or other medical devices to be cleared if it similar enough to a prior cleared device.¹ There are pros and cons to off-label use of drugs and biologics.¹ One major con is that there is a dearth of scientific evidence in humans explaining why and how the biologic works.¹

PRP in Oral Surgery

PRP is used for a variety of orthopedic purposes. Oral surgery is just one of the many ways in which this therapy is leveraged. A 2013 study of PRP in dental surgery found mixed results in the literature.² The goal of PRP for tooth extraction is to manage the bleeding and pain of extraction sockets while encouraging bone formation.² Some studies found improved benefits to post-operative pain, bleeding, and bone healing, whereas other studies found no significant effects of PRP, especially long-term for bone growth.² Overall, the review indicates that there is evidence of PRP being effective for soft tissue but not for bone regeneration.²

The body of knowledge regarding Platelet-Rich Plasma will continue to grow in the next decade. Over this period of time, perhaps the FDA approval process will be fruitful and standardized treatments will make their way onto the market.

References:

1. Jones IA, Togashi RC, Thomas Vangsness C. The Economics and Regulation of PRP in the Evolving Field of Orthopedic Biologics. Curr Rev Musculoskelet Med. 2018;11(4):558-565. doi:1007/s12178-018-9514-z
2. Albanese A, Licata ME, Polizzi B, Campisi G. Platelet-rich plasma (PRP) in dental and oral surgery: from the wound healing to bone regeneration. Immunity & ageing. 2013;10(1):23-23. doi:1186/1742-4933-10-23

How long does a dental crown last? The answer is, “It depends.” In this blog, I will review how I manage answering this question for my own peace of mind and to reduce disappointment for my patients.

All of us can think about crowns that are currently in our patients’ mouths that have been in four decades or more…crowns that are doing fine. Sometimes, we look at a bite wing of one of these restored teeth and see space enough “to drive a truck” between the margin and the natural tooth structure. Yet, the crowned tooth is fine with no caries.

We also can think about crowns in our patients’ mouths that needed to be or now need to be replaced within five years or under…perhaps, even within two years. Some of these crowns were carefully and beautifully done.

We have a habit of thinking: The better our skill is, the greater is the longevity of the crown. We need to get away from this generalization because there are numerous factors that impact longevity.

Yes, the dentist’s skill is a factor as are the amount of time and energy we put into making it exquisite, the quality of the laboratory, and the materials. But the other part of the equation is that we put dentistry into the mouths of human beings, and human beings come with risk factors. The most common reason we replace a crown or filling is recurring caries. We see some patients who have new carious lesions every time we see them in the dental chair. They are at high risk. At the other end of the spectrum, we have patients who have not had a carious lesion in multiple decades. The functional risk of the patient is the second primary risk factor. We have patients who can break any type of crown, and we have other patients who have no evidence of functional risk.

What do I say to my patients? I tell them dentistry does not last forever, and there are challenges in predicting the lifespan of their restorations. I do not say, “When your crown fails at some point in the future, it will need dental treatment again.” Instead, I say, “We’re going to treat this tooth with a crown. At some time in the future, it will need treatment again.” Then I say, “The most common reason why a crown needs to be replaced is dental decay around and under the crown, and what we know about you is that you tend to get cavities [or not get cavities]. The second most common reason we replace crowns is that they break. The materials cannot withstand the forces. And what we know about you is that you are tougher on your teeth [or not as tough on your teeth] compared to many other people. “

This type of conversation makes most dentists nervous. They fear the patient will not want to do the crown if the patient knows they will eventually need to retreat the tooth. That has not been my experience. The reality that cars do not run forever does not stop us from buying a new car. The knowledge that your roof will last 10 to 14 years does not stop us from replacing the roof. The reality that the tooth will need retreatment in the future does not stop us from having it treated now.

Setting realistic expectations results in less patient frustration, sadness, and disappointment. It also lessens conflict between the dentist and patients. I want my patients to understand the reality that dentistry does not last forever. It all has a lifespan, just like a car or washing machine. Any tooth we treat will need to be treated again. I also want them to know their risk factors for decay or breakage relative to other patients. Is it high? Is it low? Is it somewhere in between? We can then have a conversation about what they can do and what we can do together to minimize those risk factors.

I bet many of us feel like we are living in a movie these days.  I’m sure you have compared this pandemic to any number of movies. The first movie that comes to mind is  Jaws. In that movie, everyone wanted to know when it will be safe to go back into the water. And now, forty-five years later, people are asking a similar question: Is it safe to go back to the dentist?

Let’s explore the parallels.

The year Jaws came out, 1975, I was serving as a Captain in the Dental Corps at Ft. Dix N.J. During my time there I came down with Hepatitis B. I became infected from working on a patient…without gloves. Remember kiddies, this was 1975…there were no rules. It was The Wild Wild West in health care. As we all know, hepatitis is caused by a blood-borne pathogen. I became quite jaundiced and severely ill. I spent two weeks in the hospital. I started feeling better after one month.

I felt good enough to go back to work, but the U.S. Army had other plans. I couldn’t go back into the clinic until my liver enzymes were back to normal. I was tested frequently not only by the military, but also by the county Board of Health. I remember how diligent they were about the testing. They were serious…I couldn’t go back to work until I was cleared. That was mostly to protect anyone I would come into contact with. I was a known carrier, unlike the infamous Typhoid Mary who carried her disease covertly. I’m sure the public was grateful that the government was acting so responsibly. Like today, the public health department’s job is to protect the public. That trust must exist for us to function as a society.

Fast forward to 1981. I was practicing full-time in my own private practice when the AIDs epidemic arrived in the U.S. By then I had learned my lesson and I was one of a small number of dentists who wore gloves on a routine basis. But I was in the minority. AIDs changed our entire profession. By the time it was over (if it ever truly was over) the life of every dentist changed forever. This time around I learned how serious government could be in enforcing public health regulations. They meant what they said. (For those who are interested look up the case of Kimberly Bergalis). This was a classic example of the combination of bloodborne pathogens and dentistry.

One thing I noticed during that period was the public awareness of dental practices and sterilization techniques. AIDS changed everything. It wasn’t the isolated patient who wanted to see how instruments were being sterilized. Many people stayed away during the height of the crisis. In time the fear eased up but not before more stringent rules and regulations were enforced. And once again the public was grateful.

Now… almost 40 years after AIDS we have a new pathogen – the coronavirus– Covid-19. The biggest difference is that this one is an airborne pathogen. And that makes all the difference in the world. Fear is ubiquitous. There is a new shark in the water. Like Typhoid Mary, it does not show its fin.

Safety is a big concern for most humans.

Behavioral psychologist Abraham Maslow formulated the Hierarchy of Needs. At the very base of the Hierarchy are physiologic needs like food and sleep followed by safety and security needs. His theory stated that people would not seek satisfaction of higher needs (love, belonging, self-actualization), until the basic needs were met.

Forty-five years after Jaws roamed the ocean it is generally safe to go back into the water, but rest assured, we do know one thing… there will always be new and more dangerous sharks to worry about, and when it comes to humans, safety is a basic need after food and sleep.

Patients have been deciding on the essential nature of dentistry forever.

As long as fear remains and people do not have the absolute certainty of safety, they will not return to dental offices except for services they perceive as essential. If your client base is full of people who are truly health-centered and trust you, your routine dental services will thrive in the pandemic. Your patients won’t wait until they are in pain to book an appointment.

But that’s the test of what you are all about, isn’t it?

If your routine services are not thriving, then your practice has had a history of attracting a broader market of people. How is that working out for you now? Beyond COVID-19, if you are in private practice, pay extra attention to targeting individuals who want the finest health and give them ample reason to trust their safety with you… no matter what.