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When the FIVE's don’t JIVE

5/31/2018

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The problems of missing and ectopic second bicuspids

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Severely ectopic LR5 had to be removed. © 2018
PictureLook at the UL5 90 degrees rotation!© 2018
3 Facts for your consideration:
  • The “5’s”, or second bicuspids are statistically the third most-commonly congenitally anomalous teeth, misshapen, ectopic eruptive positions, and missing.  (The first two are wisdom teeth and upper laterals.)
  • The predecessor primary/baby tooth,  the “e” tooth, is typically 2-3 or more mm wider mesio-distally than the 5’s.  
This provides extra space in the arch between the 6 year molar which erupts distal to the “e”, and the lateral incisor, so that the 3’s, 4’s, and 5’s (permanent canine and first and second bicuspids) have space for eruption.
5 Things that can throw the system off:
  1. Missing permanent 5’s.
  2. One or more bicuspids in poor developmental/eruptive position
  3. Eruption sequence out of order, so space is lost early, OR held too long by a primary tooth, most often the “e”.
  4. Ectopic position after eruption, often rotations, sometimes as much as 90∘
  5. There is no space for lower 12-year molar eruption, and 5’s are crowded out.
  6. Profile is protrusive, and if all teeth remain in the arch, the protrusion is unesthetic.
For 5-eruptions to work well, the following 3 are necessary:
  1. All permanent teeth are present.
  2. All permanent teeth must be in relatively good eruptive position.
  3. The sequence of primary tooth exfoliation is ideally... 
    Upper: the “d” exfoliates and the 4 erupts the “e” exfoliates and the 5 erupts right away before the 6 year molar has a chance to mesialize the “c” exfoliates and the 3 erupts last
    Lower: the “c” exfoliates and the 3 erupts the “d” and “e” exfoliate about the same time and the 4 and 5 erupt without the 6-year molar having time to mesialize.


5 Things you do to reduce the risk of FIVEs not jiving. (Which will help provide better chance of the necessary factors above.)
  1. Clear the path (extract primary teeth that are in the path)... as early as the panoramic demonstrates an ectopic trajectory is obvious... ascertain LLA (lower lingual arch, Nance or upper lingual arch)... is in place to avoid any mesialization of the 6 year molars  (save the precious “e” space)
  2. Use a UAW (Utility Arch Wire) to create space
  3. If severely ectopic trajectory, removal may be needed at some point
  4. Utilize various orthodontic techniques to derotate a rotated bicuspid as soon as it erupts, before the interosseous and interdental fibers develop
  5. Include in a comprehensive orthodontic treatment plan, the removal of a bicuspid that will facilitate successful eruption and successful occlusion of other teeth, including the 12 year molars, or removal of bicuspids when it will facilitate the most beautiful profile.
You can reduce treatment time, reduce frustration for you and for your patient, and improve your finished results by utilizing the above treatments in your orthodontics.

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No space for 7’s and protrusive profile: plan to extract L5’s. © 2018 Dr Chris Baker.
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UAW’s to create arch length for 3,4,5’s. © 2018 Dr Chris Baker. All rights reserved.
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Unerupted L5; parents don’t want to remove now; hope for eruption. Completed ortho, removed braces… 5 is holding bone for implant. © 2018 Dr Chris Baker
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Make What Looks Impossible to be Possible in Your Dental Practice

5/29/2018

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Relationships are transformational for your dental practice. Deal with your patients with absolute love in your heart.  

"If words come out of the heart, they will enter the heart. If they come from the tongue, they will not pass beyond the ears." - Suhrawardi

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I'll Do It Tomorrow!

5/28/2018

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It’s so easy to make a tiny decision that can change your life. 

That decision may be to move in a positive direction...  just a 15-minute walk today, OR,

• eat a healthful dinner, OR

• read a few pages of “pumped-up stuff”, OR 

• sit for five minutes on the side of your bed in the morning and think of the wonderful things in your life.  

Any of these are pretty easy to do.

And - they are easy not to do.  

Instead, you can walk tomorrow, OR 
• eat better tomorrow, OR 
• play on social media instead of reading the “good stuff,” OR 
• sleep another five minutes, throw the covers back and hit the shower running, feeling stressed and hurried.  
That’s pretty easy to do as well.

Whichever way you go, leads to a path - a path toward the life you want, toward the joy of living, or a path of more frustrations and difficulties.  

Your tiny decisions will decide by and for you where you ultimately end up.

Easy to do, easy not to do.  Choose well. ​

Love,
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It's so easy to make a tiny decision that can change your life. That can be as "trivial' as getting out of bed on time!
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Be able to look back at the end of each day and see that you've made a positive difference in the world.
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The Hidden Secrets the Panoramic Holds

5/24/2018

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Missing upper 2's, missing lower 5's, ectopic canines. © 2018 Dr Chris Baker
The Panoramic radiograph.  You may be surprised to discover the amazing information you can find about a child patient in that x-ray.  Can you name five really important findings in a panoramic on an early mixed dentition patient?

Can you name six?  Seven?  Let’s go for double that figure! (And we won’t include decay, as it’s not the best diagnostic tool of decay.  Well, on second thought, maybe we will include some  possible decay-related findings at the end of our discussion.)

The panoramic should be taken when any permanent teeth are erupting.  Often those first eruptions are the lower incisors, or the six-year molars, but no matter what teeth, take the pano then.  (You may find opportunity to change the child’s life because of the secrets that x-ray holds.)

Start by counting/identifying all teeth (Sounds pretty tame and familiar so far!) :
  1. Missing teeth.  Count ‘em.  Every single one.  Be sure.  Most often upper lateral incisors, and bicuspids, but maybe any incisor, any tooth actually.  While severe “anodontia” is typically related to Ectodermal Dysplasia, and other developmental disorders, any permanent tooth can be missing even without identifiable developmental disorders "with names.”
  2. Extra teeth.  Supernumerary teeth can be anywhere.  One of my patients had one that looked like a canine, but about the size of a primary canine, in the floor of the nose, over the bicuspid root area. 
  3. Malformed  and unusual teeth.   While ectopic and unusual trajectories of eruptive paths can cause dilacerations, there may be malformed crowns as well.  Note any taurodontic primary molars that may hinder exfoliation, dilacerated roots that may hinder eruption, or if the dilacerated root is next to a missing tooth space, it could prevent implant later.  Notice now.  Notice incisors with talon lingual cusps/dens evaginates, and shovel-shaped incisors with scooped out lingual surfaces which may be more at risk of decay at the cuspal interfaces, and may create occlusal issues in contact with the lower incisors.  
  4. Variations in sizes of teeth. Notice particularly large lateral incisors as well as peg or small laterals which may also interfere with occlusal harmony.
  5. Fused or possibly fused teeth; or geminated teeth.
  6. Ectopic teeth positions, which can portend huge difficulties in getting the teeth into the arch later, or even contribute to transpositions of teeth, and certainly to extended orthodontic treatment.  If normal eruption does not occur, ectopic teeth may need to be orthodontically moved over larger than normal distances, and past other tooth roots.  This predisposes both the ectopic teeth as well as the teeth in the path of the movement to potential damage, including root resorption, loss of vitality, alveolar bone loss and gingival and per problems, and some ankylose,
  7. Stage of exfoliation and eruption
  8. Poorly resorbing roots on primary teeth - is it due to ectopic position of succedaneous permanent tooth?  Is the permanent successor missing?
  9. Submerged primary molars - actually probably due to an ankylosis or other failure of the tooth to undergo normal eruptive growth with the adjacent teeth.
  10. Crowding.  Eruption issues to come.  Opportunity to clear the path of eruption and prevent more complex problems and need for extended treatments.  
  11. Third molar positions.  While not usually evident in the earliest mixed dentition panoramic x-ray, often are notable within a year or two.  Horizontal and severe ectopic positions may affect the eruption of the twelve year molars, and should be monitored for need for early removal to allow eruption of the twelve year molars.
  12. Twelve year molars that do not have the space to erupt in the mandible.  As human jaws get smaller, and teeth do not, we are seeing more 12 year molars that will never be able to clear the mandibular ramus, like many third molars.  Not frequent, but more and more so.
  13. Class II or III occlusion (at least as screening, to be evaluated further.)
  14. Atypical incisive papilla alveolar bone area.  Again, screening, to be confirmed with diastema, low and deep pull frenum, etc.
There you have some great secrets the pano may hold.  Nice not to be surprised later when it is later, and things have gotten way complex.  Think about what you can do for your patient when you take panos at the time of eruption of permanent teeth. 

Here’s an important opportunity to do outstanding diagnosis for your patient, and be paid for your care.  You’re in dentistry to care for people, and in business to make a living.  
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Missing LL5, and severely ectopic LR 5, which had to be removed. © 2018 Dr Chris Baker

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Use the Right Systems to Bring Ortho into Your Practice

5/22/2018

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Using the ​right systems is the "secret sauce" to successfully implement an orthodontic program in a general or pediatric dental practice. 

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Guard Your Time!

5/21/2018

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Guarding your time is an important factor to living a great life. Avoiding website distractions and needless emails are good ways to guard your time.
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So many things take away your time.  A few tips to help you keep more time for you and what you REALLY want to do with your time.

1. Keep email from taking your time. 

• Keep your personal and work email addresses separate;

• Consider a second personal email to give when an email is required for purchases and other consumer online activities.  Yes, you have to check it, but those aren’t cluttering your private, personal email box.

• Take a few minutes once a week or more, to unsubscribe  to any and all unwanted sites that have started emailing you.

2. Avoid website distractions that can eat up an hour or two before you know it!

• It’s too easy to get stuck on social media, news, and so on.  ONLY do those when you want a bit of a break from work, and even consider setting your phone timer for 10 minutes.  You’ll be amazed how fast that goes!

• IF you want to play online, and that is your choice for your down-time, then go for it.  But if you have a chance to get outside, exercise, spend time with family, or other things, then keep the screen from owning your time!  Set the timer!

• Have a list - EVERY DAY.  Your to-do list will help you stay focused and productive.  That will leave more time for YOU.  Keep on it.  Get what you can done.

Dr Walter Doyle used to tell me to pick up the paper ONE TIME and complete the task.  In other words, look at the list, choose a task and do whatever you can NOW to complete or to get the task going for now.  Then next task.  Avoid looking at the list, starting a task, setting it aside, getting distracted, etc.  Do it, and move along.


Love, 
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Your dental practice is not a charity: YOU decide what your missionary work will be

5/17/2018

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PictureSome of the past officers of the American Orthodontic Society. Past President, Dr Chris Baker, is on the very right.
Choose freedom over paying some corporate CEO’s country club membership...
  • Freedom to get up in the morning and look forward to going to work.
  • Freedom to get to work to make money for you and your family and not for other people -- like insurance corporations and government.
  • Freedom to diagnose your own patients and not have insurance tell you when you can do a pulpotomy and stainless steel crown, same appointment or different appointment,  in what sequence to get paid for them both.
  • Freedom to set your own fees because you know what your overhead is
  • Freedom to have a practice that actually functions as your business and not as an arm of a big corporation and government.
  • Freedom to incorporate systems into your practice that don’t require you to jump through hoops set up for you by insurance companies and Medicaid, so you will actually be profitable over the long haul, and have a business to sell when you are ready.
  • Freedom to take good care of your patients and not spend all of your time filing claims, filing appeals, answering questions and still not getting paid.

Benjamin Franklin warned of the kind of situation where little compromises sacrifice such freedoms; “Make yourself a sheep and the wolves will eat you.” 

Opt into a free market medical model - and YOU decide what your missionary work will be instead of being a member of the unpaid robot dental collective.


Dr. David Gesko, in a recent interview, notes, if you're concerned about dental therapists from a competition standpoint, dentistry as a whole is changing, and you may have to get used to new technologies and models of care. (emphasis mine)1

Choose freedom over being required to change your “model of care” (How about if you go out of business, and two dental therapists with high school educations replace you?) Use a free market model, instead, that makes you independent of big insurance, big government and big corporations.

It seems the biggest advocates for cheaper dental (medical) care are executives of huge corporations, receiving very generous salaries.  The young dentist out of school with a half-million dollar debt needs his/her profession, his/her job, his/her ability to proceed with a career, take care of a beloved family and get out of debt.  

Dr Gesko is Dental Director and Senior Vice-President of HealthPartners, a corporation which reports “serving over 1.5 million members.” 2  His biography says, “Dr. Gesko is passionate about integrating medical and dental care and applying growing evidence-based research to care delivery.” (emphasis mine)2 

Dr. Gesko, a Minnesota Board of Dentistry member, and now President of the Board, says he has worked alongside dental therapists since their inception. So far, he's had “positive experiences and so have the low-income patients at HealthPartners' dental clinics.”1

Use a model to create a life where you are free, prosperous, and happy.  You can use situations and systems which, if implemented, will give you the interesting, wonderful, and prosperous practice you deserve. You can take better care of your patients, family, staff, and be a better member of the community, by implementing the systems we teach.


At Love & Orthodontics, we are here to help the dentist have the practice of his/her dream. You, the dentist can have a happy career that is prosperous and free of harassment from insurance companies, big corporations and government over-regulation.

Fear knocked at the door
Faith answered.
No one was there.


1. https://www.drbicuspid.com/index.aspx?sec=sup&sub=pmt&pag=dis&ItemID=323014

2. http://www.marshfieldresearch.org/iosh/biography-of-david-gesko

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Doctor, are you dancing on the tracks?   (Video)

5/15/2018

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The best treatment of the patient, doctor, is still YOUR responsibility.
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Family Time

5/15/2018

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An idea.  

Carve out dinner times as often as possible, to be together. 

To be at peace. 

To share your day.

To enjoy each other. 


We need to become aware of studies that show us that children are being damaged by screens and by the content on those screens and of studies about the high risk of cancer from screen use. And, of the breakdown of families and the terrible impact on all.

SO - picture dinner times as often as possible, together as a family, all devices out of the room, and talk and sharing with the food.  Even include preparation of the food.  How about making a delicious soup, and serving it with a healthful toast?

Here’s a wonderful, easy, quick recipe that could be fun for you all to make:

Yummy Butternut Squash Soup - makes about 4-5 servings

• about 8 cups of fresh cubed butternut squash, which you can find in the produce section of most groceries;
• Olive Oil;
• about 20 oz. of vegetable or chicken broth;
• about 2 c Heavy Cream;
• A large bag of baby spinach and a large chopped onion to saute to serve with your soup;
• Creme fraiche or sour cream or yogurt.

Preheat oven to 350 degrees.

Turn squash cubes in oil until well coated.
Put onto baking sheet or baking pan, single layer, and roast at 400 deg for about an hour, until they are brown on the edges.

Can refrigerate at this point until ready to make the soup.

Blitz squash with broth in processor or with stick blender, and heat through.  Add cream

Saute chopped onion in olive oil, remove, then a bit more olive oil, and dump your large bag of spinach into the saute pan and saute til wilted.

Serve your soup as you wish -  top with your sautéed spinach and onion, creme fraiche, sour cream or yogurt, and. and sprinkle with red chili flakes if you want a touch of spicy,

Yum.

Love,

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A fast train is coming.  Are you dancing on the tracks?

5/10/2018

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In pediatric dentistry, these days it is de rigueur, fashionable, in vogue, all the rage, trendsetting,  and chic to avoid dental techniques that the child patient and the parent don’t like.  And, who likes being a restorative dental  patient? 

And what parent likes having their child not like something?
So, the result is the trend away from the customary, conventional, standard restorative treatments, and toward “minimally invasive” and even “non-invasive” treatments.  

These fashionable offerings basically ignore the bacterial etiology of dental decay and soft tissue inflammation and infection, with a nod to making it easier, more acceptable to the child, and thus to the parent.  Certainly those of us who treat children have experienced the question, "Johnnie, do you want to have your tooth fixed today? (Variations; “pulled", "pulled out", "numbed", "have a shot," etc.)  

What child would not answer, “No”?  We could go into the point that’s why children have parents, to make the difficult decisions that will most benefit their children, but even that point is not the point here.

So, it is becoming de rigueur to treatment plan the more acceptable treatments that do not address the bacterial etiology - hear me - as well - and keep everyone happy.  Even our “evidence base” finds the Hall SSC technique of covering a decayed tooth with an SSC (often without any decay removal) as acceptable. 

So the virulent organisms are locked into the tooth where they can travel through dentinal tubules into the pulpal circulation and into the systemic circulation.  My job is not to judge the research, nor the treatment, but to have you consider - and question - what the sequelae to these directions may be.


"Minimally invasive” techniques include diet counseling and sugar substitutes, sealants, antimicrobial agents and chemotherapeutic approaches, remineralization of early lesions, GIC, fluorides, CPP-ACP, and others.  

Let’s think about those first.  Have you many parents in your practice who truly take the information to heart and...
a) change the child’s diet ,
b) actually use the antimicrobial agents, fluorides, and other chemotherapeutic agents over even a short period of time, and regularly? 

​It begs the question, “How’s it workin’ for ya?”


Then the minimal surgical interventions of decay, including ART, chemo-mechanical caries removal (Sodium hypochlorite + mechanical removal), air abrasion, lasers, Hall technique, Silver Diamine Fl, and so on - while these are newer on the scene, how do you feel those approaches transform the child’s history and future of decay?  (An attorney in my family responded that on behalf of all attorneys, he might just mail a thank you note to Dr. Hall, whoever he is, for his technique that makes it just a matter of time before he earns a very good living for attorneys.)

It’s the “How’s it workin’ for ya?” again.

HOWEVER, we as pediatric dentists LOVE to please the parent and child.  Most folks who go into dentistry are... 
a) in it to help people and change lives, and... 
b) approval addicted such that it is a common goal to do whatever possible to get people to LOVE you. (That includes not charging either anything for some procedures, or at least not much, not “bothering the child patient if possible, using GA, sedation, etc.)


So, these less invasive, hated treatments appeal to us as well as to the parents and child.  Sort of.  We convince ourselves it is good.  

That train is carrying other cargo as well.

Think about:
  1. Big Pharma continuing to develop chemo-therapeutic agents that may or may not be very effective, but do cost a lot, and with still-to-be-determined side effects and sequelae.
  2. ADA is developing new procedure codes to demonstrate these techniques.
  3. The insurance companies including Medicaid, perhaps especially Medicaid, are talking in their planning meetings, about how they can cover the “less invasive”  treatments and not the conventional treatments - why?  because they can cover them at a much lower rate, even though they are not necessarily even beneficial.  (Another way the companies siphon off money at the expense of the patient, with poorer and possibly in-effective care, and at the expense of the doctor, who cannot be reimbursed even if a conventional or better therapy is warranted if it’s not “covered”.)
  4. The big-box, corporate dental centers who already mandate what procedures their often young and inexperienced dentists are to do, can take advantage of the finances the same way.
  5. The doctor is ultimately licensed and responsible to do no harm, to care in the highest and most professional way for each patient and each disease situation. The best treatment for the patient is still the responsibility of the doctor.  The parent expects that, as well as letting their child decide about treatment.  This is a crazy situation.  It certainly is. 
  6. With further decreases in “coverage” (insurance-speak for what they will pay,) the participating dentist is locked into missionary work they did not realize was their mission. 
“I hear a train a’comin’. It’s comin’ down the tracks.  And I ain’t seen the sunshine, since I don’t know when…that train keeps rollin’… I bet there’s rich folk eatin’ from a fancy dining car.  They’re probably drinkin’ coffee and smokin’ big cigars.  Well I know I had it comin’ I know I can’t be free.  But those people keep a movin’ and that’s what tortures me.”   
~ Johnny Cash


Doctor, are you dancin’ on the tracks?
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    Dr Chris Baker

    America's most-trusted teacher of orthodontic continuing education, Dr. Chris Baker has practiced and taught for more than 30 years, and is a current or former faculty member of three U.S. dental schools.  She is a pediatric dentist, author, blogger, dental practice consultant, and mentor.  Dr. Chris is also Past President and Senior Instructor of the American Orthodontic Society.  She is based in Texas, USA, but lectures around the world.

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