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Howard Speaks Howard Farran, DDS, MAGD, MBA, Publisher, Dentaltown Magazine

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The Future of Dentistry is Crumbling Away
– by Howard Farran, DDS, MAGD, MBA, Publisher, Dentaltown Magazine

The future of all the dentistry we are performing on our patients right now is crumbling before our very eyes. Did you know the fastest growing segment of the U.S. population is 100 years of age or older? Did you know the second-fastest growing segment is age 90 and older? In 1900, the United States invested one percent of its GDP in the health-care market; today, America invests 17 percent. People are living longer – and that's great, but how do their mouths look?
As people keep living longer and longer, we're seeing the oral health of the oldest segments of our population rot away at an alarming rate. Day-to-day oral care for these segments is certainly a contributing factor, but you wouldn't believe how much saliva has to do with it.

When you cut your finger, what's the first thing you do? You jam it in your mouth and lick it clean, right? Mammals instinctively lick their wounds because saliva has antibodies in it. If a baby chimp shows its mother a cut on its arm, she licks it. It's instinct. Some people think that's why mom kisses junior's boo-boo when he takes a spill on the playground – it is just another way to apply saliva to the wound.

Tonight, walk into your child's room when he's sound asleep and you're going to find a softball-sized puddle of drool on his pillow. Go ahead and pick him up and that string of saliva will stretch for a foot before it gives. He has so much spit it's amazing he doesn't drown in his sleep every night. Now think about your 40- and 50-year-old patients who might take a glass of water to bed with them because when they wake up in the middle of the night, their mouths are drier than the Sahara. By the time we reach 65, we all take a glass of water to bed with us. As we age, our saliva dries up, and when you don't have saliva in your mouth you don't have antibodies, which help prevent tooth decay.

OK, now send Nana to a nursing home with a mouthful of paid-for, high-quality dentistry. Her saliva is already shut down for the most part, so she's not likely going to wear a denture (if you don't have any saliva or mucus in your mouth, the denture is just going to rub wear spots and be uncomfortable). Because Nana's not wearing her denture, and the cook knows this, the entire menu is cottage cheese and macaroni and cheese and lemon meringue pie; Nana can't eat chicken, fish, steak or broccoli. She's carb-loading every meal of every day. It's sugar city in her mouth, and the bugs love that. Nana already has dry mouth because of her age, but combine that with the side effects from the medications she's on. According to statistics from AARP the average American older than 75 has more than 11 drugs prescribed to them each year. Antihistamines, antidepressants, anticholinergics, anorexiants, antihypertensives, antipsychotics, anti-Parkinson agents, diuretics, sedatives, antiemetics, antianxiety agents, decongestants, analgesics, antidiarrheals, bronchodilators and skeletal muscle relaxants all contribute to xerostomia – and chances are, Nana's on a bunch of them. Cap that off with the oral care Nana receives (or, more appropriately, doesn't receive). She can't brush or floss her own teeth, and the RN doesn't spend much time or effort scrubbing her mouth for her. Add all these factors together and all the work done in Nana's mouth for the last 65-75 years rots out in less than a year. It's sick and it's depressing.

Every time I do a root canal on a 65-year-old patient, I'm demoralized. Nana comes in and wants to give me $1,000 for a root canal and a build-up, and another $1,000 for a crown. It takes me an hour and 30 minutes, in and out. But when she walks out the door, I think, "Oh my god, she just gave me $2,000 for that. Life is great at 65, but in 10 years her husband will die, she'll fall down and be unable to get up, her kids will put her in a nursing home, and she'll be on 11 different medications – seven of which are severely drying out her mouth. And if I visit her in the nursing home in 10 years, that $2,000 root canal, bridge/crown I did will be mush. It will be entirely root surface decay."

I realize I shouldn't have done the root canal. I shouldn't have done the crown. I should have extracted the tooth and placed a root form titanium dental implant with a crown, knowing full well that it will survive in her mouth in the nursing home better than any restorative treatment. Restored teeth in a nursing home are Ritz crackers for Streptococcus mutans. It kills me every time I do a root canal on a 65-year-old patient. I don't know why I keep doing it, aside from the fact insurance will cover 80 percent of the root canal but won't cover an implant (which Nana ain't going to pay for) and Nana says she wants to keep as much of her natural dentition as possible. Still, it's the wrong decision.

There's a field in dentistry that hardly anyone talks about – geriatric dentistry. As our nation ages over the next 25 to 50 years, this is going to become one of the most important and fastest growing specialties in the dental profession, without a doubt. You're going to see more and more mobile dental vans than ever. In fact, I bet the next $100 million dentist will be someone who owns a fleet of Winnebagos that are retrofitted into mobile dental offices and hang out in nursing home parking lots all day. Transporting Nana from the nursing home to a dental office is difficult, but wheeling her out to a dental van in the parking lot is a no brainer. Probably one of the reasons you don't see a flood of dentists getting into geriatric dentistry right now is because geriatric dentists are as demoralized as I am after doing Nana's root canal – except you can multiply their dismay by about a thousand!

I recently spoke with a dentist who did a two-year specialty in geriatrics at UCLA. She said she felt her job was a lost cause. She told me she might spend four hours doing 14 fillings on Nana in the nursing home. Six months later she pays Nana another visit and every single one of those fillings has rotted out. She said if she places amalgam or gold, maybe half of them make it, and at that point in their lives they're too old to do implant surgery. No oral surgeon will touch them – they can't put them to sleep because they're too fragile, they can't lose too much blood and they don't have any bone marrow. Every single geriatric dentist I've talked to says the entire dental profession has no idea what is going on with the teeth of people who live in nursing homes. I once asked a room full of 300 dentists how many of them visited a nursing home in the past year to do any kind of palliative dental treatment. Do you know how many hands went up? Zero.

So What Ought to be Done?
If we want the future of our dentistry to succeed and the geriatric dental specialty to flourish, all of the major dental companies need to sit down and invent an automatic toothbrushing machine – like a carwash for teeth. We don't need another electric toothbrush – Nana can't use it. The RNs and LPNs who work at the nursing home need a new device that they can stick into Nana's mouth that, when she bites down, it thoroughly brushes and rinses her mouth like an automatic carwash.

The second thing we need to do is incorporate pH balancing oral rinses into Nana's daily routine. Especially with her diet in the nursing home, her mouth is an acid bath where bacteria love to live. You have to check out Dr. Kim Kutsch's research (www.carifree.com). He's put his heart and soul into developing effective, pH-balancing, caries-reducing oral rinses, and they are going to change preventive oral care. Nana needs oral rinses because she can't floss or brush her teeth on her own. Look into xylitol products from companies like Xlear, as well (www.xlear.com). Oral rinses are what keep the acidity level neutral in Nana's mouth.

The third thing we need to do is say, OK, we've figured out bonding strength, colors, translucency, shades and wear rates – but now these composite fillings need to become bacteriostatic or bactericidal like amalgams. Composites need to be able to inhibit the growth of bacteria, or just kill it. All fillings need to become toxic to dental decay. Period.

Bottom line, guys: We either solve this problem or we need to stop doing root canals on 65-year-old patients and start doing implants and fixed and removable dentures. Right now, the more money, time and effort you pump into saving Nana's natural teeth, the faster she becomes a casualty of a bacteria war we'll never win.
Howard Live
Howard Farran, DDS, MBA, MAGD, is an international speaker who has written dozens of published articles. To schedule Howard to speak to your next national, state or local dental meeting, email colleen@farranmedia.com.

Dr. Farran’s next speaking engagement is November 29 through December 1, 2010, at the Greater New York Dental Meeting in New York, New York. For more information, please call Colleen at 480-445-9712.

Seminars 2011
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Sioux City Dental Society
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Professional Success Institute
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