Do I need to Premedicate anymore?

I graduated Columbia’s School of Dental & Oral Surgery  in 1994. At the time, the consensus recommendation established by the medical community was such that, “anyone who had a heart murmur should be premedicated prior to their dental visit, for life!”

As a matter of fact, the accepted protocol for dental premedication was a whopping mouthful—- 3.0 grams (6 x 500 milligrams pills) one hour prior to a dental appointment and then 1.5 grams (3 x 500 milligrams) eight hours after the initial dose.  To say nothing of the stomach upset………

Why should I premedicate? What is the thought behind premedication?

The thought behind premedication is based on transmission of bacteria. By the same token, transplanted bacteria from the mouth can act as a source of infection in another part of the body. Moreover, a simple local anesthetic needle puncture in the mouth can transport it from the cesspool of the mouth into the patient’s bloodstream. This bacterium, transported mechanically, would then be free to stroll the corridors of blood vessels. It can then nefariously deposit itself onto an already troubled heart valve or bionic prosthetic joint. To that end, it “sets up shop” and initiates a destructive process of tissue destruction. Subsequently, the patient can incur a shredded heart valve or a diseased prosthetic joint. Antibiotic premedication blasts those pesky bacterium dead. Essentially, the antibiotic blast creates a temporary sterile environment. Therefore, premedication offers a lesser potential for tissue damage.

Then and Now…….

The literature is all over the place.

Antibiotic prophylaxis is recommended for a small number of people who have specific heart conditions. The American Heart Association has guidelines identifying people who should take antibiotics prior to dental care. According to these guidelines, antibiotic prophylaxis should be considered for people with:

  • Artificial heart valves. 
  • A history of an infection of the lining of the heart or heart valves known as infective endocarditis, an uncommon but life-threatening infection. 
  • A heart transplant in which a problem develops with one of the valves inside the heart. 
  • Heart conditions that are present from birth, such as: 
    • Unrepaired cyanotic congenital heart disease, including people with palliative shunts and conduit. 
    • Defects repaired with a prosthetic material or device—whether placed by surgery or catheter intervention—during the first six months after repair.
    • Cases in which a heart defect has been repaired, but a residual defect remains at the site or adjacent to the site of the prosthetic patch or prosthetic device used for the repair. 

In addition, Artificial joint replacement premedication protocol is just as ambiguous. You can find conflicting literature all over the web. It’s best to speak to your orthopedic doctor for clarity on their personal guidelines.

I have my own opinions about premedication. I look forward to expanding on my ideas on my upcoming video release this weekend on my You Tube Channel. Stay tuned :

You Tube Channel. Robert Emilio DDS & Associates

Dr. Emilio & Associates,  Always Accepts  New Patients. He especially exceeds at treating same day emergencies patients suffering from tooth ache pains.

His goal is to keep his patients’ Teeth and Gums Healthy For Life.

Feel Free to appoint a Consultation with the Doctor. Open Six Days A Week

OPEN on Weekdays.  7:30am -8:00pm  (M<T<W<T)

Fridays.  7:30am-2:00pm

Weekends (Saturday only).  8:00am-2:00pm

111 East Avenue, Norwalk, Connecticut 06851.

You can always contact me directly via email  blog@robertemiliodds.com

You Tube : Robert Emilio DDS & Associates 

Instagram:  dentist_in_connecticut

Office (203)866-7164      www.robertemiliodds.com

Why does it hurt? I had the root canal.

The Presentation

An existing patient of my practice presented today complaining of soreness on chew, especially something hard. “It hurts somewhere up there, on top to the left”, she said.

The Analysis

The first thing to remember; there was no swelling of the patient’s face, nor around the gum of the teeth in question. Another key point, was that there was no response to cold or hot stimuli. Specifically, the patient exhibited a dull pain upon chewing down on my carefully positioned cotton roll. Subsequently, a radiograph of the maxillary first molar area was taken by my assistant. Behold! Not to mention, THIS TOOTH WAS PREVIOUSLY TREATED BY ME WITH ROOT CANAL THERAPY SEVERAL YEARS AGO. Moreover, the radiograph demonstrated an area of radiolucency (black shadow) just at the tip of the roots of the first molar. In other words, this indicated inflammation/infection.

The Assessment

Failing Root Canal of the Maxillary First Molar

The Plan

For that reason. I initiated antibiotics to keep area in “check” until I can get the patient back to Re-root canal the First Molar.

The Discussion

A root canal is a technically difficult procedure performed by a dentist. The process consists of two parts. First, the dentist mechanically removes infected biological material( nerve) utilizing very fine nickel titanium files from within tooth’s core. Second, the dentist packs inert material (gutta percha) to hermetically seal this evacuated space. In effect, the dentist removes the nerve of the tooth via a micro rotor-router approach and fills the emptied nerve chambers with rubber.

But Why Did That Previously Root Canal Treated Tooth Fail?

A previously root canal treated can fail creating that annoying discomfort for any number of reasons:

The most dominant reason of failure is due to insufficient irrigation by the operator in removing the infected biological debris from within the nerve chamber and canals. In short, bleach irrigation floats debris out of the shaped canal space. In essence, remaining debris can set up an environment for reinfection. In summary, every thing biological must come out from within the tooth.

On occasion, an Accessory Canal can be missed. Incidentally, canals are extremely small; the width of a human hair sometimes. Moreover, I use magnifying loupes in practice and I still miss identifying them, although rarely. By the way, the maxillary first molar has accessory canals 69.2 % of the time.

Sooner or later, an Improper fill can lead to a seepage of bacterial laced saliva back into tooth to reinfect. This is one reason why I strongly recommend to cover and ultimately seal your root canal treated tooth with a crown.

Generally speaking, a cracked root will lead to a failure of a previously treated root canal tooth. In a word, that’s a bad failure. In the final analysis, out comes the tooth and in goes the implant.

Above all, many retreatments can be successful. In reality, a failing root canal treated tooth can be resurrected with a little bit of patience and clever skill.

Below is another one of my many successful root canal treated cases in chronological order.

There is a large infection at this lateral central incisor( Black spot at root)

The Day of Completion of Root Canal Procedure -Day 1-

Three months out. Day -90-
Look and see how black spot at tip is fading away. That’s a good sign…..
One year out. Day 365- Healthy Bone fill has replaced the previously infected black spot

Credits:

Dr. Emilio & Associates,  Always Accepts  New Patients. He especially exceeds at treating same day emergencies patients suffering from tooth ache pains.

His goal is to keep his patients’ Teeth and Gums Healthy For Life.

Feel Free to appoint a Consultation with the Doctor. Open Six Days A Week

OPEN on Weekdays.  7:30am -8:00pm  (M<T<W<T)

Fridays.  7:30am-2:00pm

Weekends (Saturday only).  8:00am-2:00pm

111 East Avenue, Norwalk, Connecticut 06851.

You can always contact me directly via email  blog@robertemiliodds.com

You Tube : Robert Emilio DDS & Associates 

Instagram:  dentist_in_connecticut

Office (203)866-7164      www.robertemiliodds.com

Pass this Link to Your Friends:  robertemilioddsblog.wordpress.com

What is a Sinus Intrusion?

The Consultation

Several years ago, a new patient presented for an implant consultation. The “spirit of the conversation” went something like this……..According to her, she was in desperate desire to chew again, on her right side. Her two previous dentists told her that in order for her to get the desired dental implant in the upper right side, she would need to get a full blown sinus lift procedure. She implored,” I don’t want that big surgery. The thought of it makes me cringe. My friend had it done and she was swollen for days. Can you help me?”  

My Introspective Thought

After that sincere plea for help it got me thinking about an alternative procedure being promoted at a dental seminar several months prior. I was thinking, rhetorically, can I do this for this beautiful lady? In brief, it was a minimally invasive procedure. Generally, I could potentially create sizable bone for the future implant. Lastly, there would be a minimal discomfort. After all, I wanted to help her. I had the motivation and glimmer of curiosity. In short, I said, “Let’s take a radiograph and I will see what I can do for you.”

The Lateral Wall Sinus Lift Procedure

A Lateral Wall Sinus Lift procedure is probably the most invasive procedure we execute in dentistry. Essentially, the dentist breaks into the maxillary sinus compartment with a drill, teases a thin delicate membrane off the floor of the fractured sinus and raises it, utilizing a set of specifically designed curved curettes. That’s to say, once the Synerderian membrane is gently displaced, cadaver bone is furthermore augmented to the newly created space to create a pseudo sinus floor. Subsequently, this augmented site provides the footing foundation for the future implant fixture. (I write about this in great detail in a previous blog. See “Sinus Lift” or visit my You Tube Channel Robert Emilio DDS & Associates, to witness the actual procedure live).

By the way, the implant can not be immediately placed until this new bone matures. Grafted bone needs to heal. Ordinarily, post operative swelling lasts about 3 days. Furthermore, this newly grafted bone can take up to six months to heal. Lastly, there’s a needed secondary surgery. Similarly, the implant must get inserted later on. Oh yes. Then there is an additional healing period of three months.

Evaluation & Discussion of the Cat Scan

To summarize, I said, “No problem”, with confidence. Furthermore, I continued on.”To begin with, how does it sound if I make a tiny incision and work thru a little tiny hole of 5.0 mm diameter? Next, I will then gently plunge saline water thru this little access hole to “push” the sinus membrane off the sinus floor. In short, it goes like this. Usually, one shot of local anesthetic is all that is needed. Incidentally, one small incision. So I then, push away the sinus membrane off the floor. Lastly, I will insert the bone graft and then finally, simultaneously, place the implant fixture. In short, does that sound agreeable? ” This is called a Sinus Intrusion Crestal Approach. To sum up, as I explained,” I can do it for you. I do it regularly(in my head)! Furthermore, book it today.”

Check it Out Live, If you Dare!

( You can see this procedure live on my You Tube Channel Robert Emilio DDS & Associates. Sinus Intrusion The Crestal Approach

Needless to say. She came in the other day for routine hygiene check. In conclusion, everything looked great. Likewise, see below radiographic progression

The Two Year Radiographic Follow Up

Pre Op Schematic. Tooth #3 Missing
Post Op. Fabulous Bone height achieved on Implant #3 (part of the bridge (#3-#5)

Dr. Emilio & Associates,  Always Accepts  New Patients. He especially exceeds at treating same day emergencies patients suffering from tooth ache pains.

His goal is to keep his patients’ Teeth and Gums Healthy For Life.

Feel Free to appoint a Consultation with the Doctor. Open Six Days A Week

OPEN on Weekdays.  7:30am -8:00pm  (M<T<W<T)

Fridays.  7:30am-2:00pm

Weekends (Saturday only).  8:00am-2:00pm

111 East Avenue, Norwalk, Connecticut 06851.

You can always contact me directly via email  blog@robertemiliodds.com

You Tube : Robert Emilio DDS & Associates 

Instagram:  dentist_in_connecticut

Office (203)866-7164      www.robertemiliodds.com

Pass this Link to Your  Friends

Why Do My Teeth Feel Sensitive?

The Story

My second patient of the day was complaining of tooth sensitivity. “It’s up there, up there on the left top, some place. When I drink cold water, it bothers me”, as she pointed upward towards my ceiling with vague clarity.

The Evaluation

During my clinical exam with my trusty explorer instrument, I ticked off my mental checklist. Exam revealed nothing out of the ordinary for this 40 year old individual. Existing fillings looked good and sealed, no cracks in the enamel of the teeth. No obvious decay. Some wear of cusps. Recession of the gums on the molar was noted. The radiograph showed nothing obvious, otherwise boring.

The Subsequent Questions I asked of my patient and my Silent Mental Response (S.M.R.) was as follows:

Q: First of all, does it hurt when you chew,,,,, just straight up and down?

A: No

S.M.R. : Good. Hence, no dying nerve requiring a root canal procedure. When a tooth’s nerve is in the early stage of dying, it swells within the pulp chamber. As a result, the tooth “pushes” itself out of the tooth’s socket only the slightest bit. Consequently, when one bites straight down on the tooth, the bruised pulp nerve with its surrounding supporting tissues get compressed. This is interpreted as, “pain on chew”. Combine chewing pain with cold sensitivity that means root canal.

Q: Similarly, Does it hurt when you chew side to side?

A: No

S.M.R. : Good. Not a fractured tooth or a fractured restoration. Either fracture would illicit the same cold sensitivity. A fractured anything, most noteworthy, allows a wicking of cold liquid within the seam of the fracture. The cold liquid gets intimately close to the sensing nerve when it is drawn thru the crack. As a result, one can feel the cold temps..

Q: Does the cold linger or does it shoot away very quickly?

A: Quickly

S.M.R. : Very Good. A healthy nerve will respond quickly and rapidly dissipate in response when the stimuli is removed ( in this case- cold water is swallowed).

The Diagnosis:

I said, “Hmmm , X-ray looks good. No decay noted radiographically. The nerve is healthy. No cracks anywhere. Some recession of the gum line of those teeth. I’m not a mind reader and it’s difficult for you to pin down which tooth……It seems like recession of the gums sensitivity. Go with the over the counter for sensitive teeth stuff and go easy on the brushing!”

The 411

A tooth’s root is poros. Within these microscopic pores, lie extended from the pulp core, tiny nerve fibers suspended in a gelatinous sea. These fibers reach out to the surface of the root and are in a direct communication with the outside world. Toothpaste for Sensitive Teeth formulas essentially are toothpastes containing microscopic boulder elements that are sized exactly to plug perfectly into the dentin pores. These microscopic pores thereby, in effect, are closed “off” isolating the nerve fiber denticles from the outside world. Subsequently, you and I interpret that effect as— O.M.G, no more pain when we drink cold water. In effect, a mechanical barrier is created (sort of like Trump’s proposed border wall). Application of this toothpaste over time creates layer upon layer of pore closings with the desired effect of less and less cold sensitivity.

Other Causes Of Cold Sensitivity :

As mentioned previously above

Aggressive brushing, decay, cracked tooth and/or a cracked dental restoration

Acidic Foods

Tooth Grinding

Tooth Whitening Toothpaste

Recent dental work

Dr. Emilio & Associates,  Always Accepts  New Patients. He especially exceeds at treating same day emergencies patients suffering from tooth ache pains.

His goal is to keep his patients’ Teeth and Gums Healthy For Life.

Feel Free to appoint a Consultation with the Doctor. Open Six Days A Week

OPEN on Weekdays.  7:30am -8:00pm  (M<T<W<T)

Fridays.  7:30am-2:00pm

Weekends (Saturday only).  8:00am-2:00pm

111 East Avenue, Norwalk, Connecticut 06851.

You can always contact me directly via email  blog@robertemiliodds.com

You Tube : Robert Emilio DDS & Associates 

Instagram:  dentist_in_connecticut

Office (203)866-7164      www.robertemiliodds.com

Pass this Link to Your 

Why Can Dentistry Fail?

Dentistry

A Quick Story about a Failure

Several days ago, I had recall a 70 year old female patient several months ago who came in for a recall visit since her last recall visit 5 months ago. Five months ago, in the hygiene room, it was determined that she had a massive implant failure in the upper left quadrant of her mouth. Three teeth on two implants were failing. There was a tremendous amount of bone that just disappeared over a period of 6 months. She had no pain or symptoms. The amount of bone destruction was radiographically staggering. The only choice was for me to remove the implants and curette the site clean. Soon after the procedure, I had a “sit down” follow-up with the patient. Nothing made sense to me. Medical history was clear. Her home care was excellent, recall great, implants not fractured, lab work looked awesome…”why the failure?” , I asked myself.

I asked the patient, “when was the last time you went for a medical check-up?” She replied, that she did not remember the last time. I suggested to start there.

Upon follow up with her PCP, it was determined that she had never gone for a colonoscopy. The GI doctor found a 5 centimeter cancerous mass in her colon with minimal metastasis. She had subsequently had the resection surgery and chemo. All was back to normal 5 months later. She currently feels great( the same prior to surgery) and we plan to replace those implants in 2020.

The Practice of Dentistry

The practice of dentistry involves, technical ability, artistic vision, emotional empathy and constant troubleshooting  of the most esoteric situations. Dentistry is 95% predictable. Technical materials and delivery systems have greatly improve over the decades. However, with that being said, not every filling, root canal or implant is a success.Why?????? I would like to think we as Dentists are only as good as our materials, but it’s much more.

Dentistry fails for either One of            Three Reasons.

First reason for failure and most common. The patient neglects home care and professional prophylaxis maintenance with routine check ups. This is tacit. You got to show up. I can catch something when it’s small,  easy and inexpensive to fix.

Second reason, “Ugh. I’m having a bad day.” The least probable and thankfully, usually not the case. We are imperfect beings working on other imperfect beings hammering away at a microscopic problem with macroscopic instruments in a sea of emotional conflict saddled from previous dental experiences. I approach work everyday enthusiastic, rested and prepared. I love being a dentist.

The third reason for failure is third party associated. For example, an out sourced local laboratory technician mis stepping in model preparation or just not reading a lab slip correctly. Sometimes their technical abilities are stretched and they may often struggle with their own limitations.

My solutions are as follows:

We have a strong recall program in the office. Eight hygienists full time by 2019. The hygienists are up to date with C.E. training and are always free to suggest their opinions on how to improve their care. Approaches to prevention and elimination of periodontal disease and peri-implant related diseases is always being updated with the most current findings.

I eagerly await to acquire more advanced educational training and knowledge. So far, I have scheduled  three dental seminars for 2019. This upcoming year, I am on track acquire 50 more C.E. hours to achieve my Full Diplomat with the I.C.O.I..  This  drive to learn more and apply fuels my passion. Everyday is my first day at work.

Third party outsourcing has been limiting over the years. I currently create 90% of my dental work via the CEREC in house lab CAD/CAM and milling unit.This control ultimately insures a better product for you. The Dental Laboratory as I knew it, will be no more. The great Old school technicians are a dying breed,  and  sadly shall be never more.

The 5% Stress

What about the other 5%? The human body ultimately decides on what works. Dentistry is invasive.  My feeling is that the body when stressed with a subtle covert underlying illness may not be able to tolerate an additional stress such as a dental implant, a root canal or a bone graft for example. Immunity resistance is a subjective quality that can not be quantified or measured. It’s best to know your body and respect it’s limitations.