Dental Info

I  believe that using a Waterpik as an adjunct to brushing and flossing can help my patients keep their gums healthier. I have already covered the reasons in earlier posts but suffice to say it facilitates fluid exchange of sulcular fluid around the roots of the teeth and can cut down on gingival inflammation.  Many of my patients, who live in apartments with relatively small bathrooms, complain that they don't want to use a waterpik in their bathroom because it needs to be plugged in. They have often commented that they would be more likely to use a smaller battery operated model. The problem is that most of the battery operated models are much less powerful and probably less effective. When I went to the Greater New York Dental Convention at the end of November I stopped by the Waterpik booth and asked them what they had that was new and they showed me a battery operated model called the Ion Professional. It is smaller than their standard plugged in models and it has a recha

As of December 6 th Mayor de Blasio announced that  all private-sector workers must provide proof of vaccination to their employers, and all employers must keep a record of each worker's proof.  In addition employer's must: - Post an official sign-in document in an obvious spot. After December 27th employees must show proof of their Covid vaccination to work in-person. This mandate applies to dental offices and their staff as well and Dentists must comply or face fines from the city. At this point it is hard to believe that some dental staff have not been vaccinated and the vast majority of our workers have been. That being the case, it is time for the last hold outs to get their vaccine or get furloughed without pay.  Of course this minority has the option of seeking a job outside of NYC, but I can't think of a good reason not to get vaccinated. I have heard most of the arguments against vaccination, but none of them are convincing and clearly going unvaccinated exposes

 My son is approaching graduation from NYU  College of Dentistry this spring. Today he had an interview for a possible general practice residency. When he was done he called me on my cell phone to ask if we should have lunch together at my office. I said yes, of course , and went back to my patient who was listening to our conversation. Lately I have been listening to a playlist from my iPhone and my sons call was broadcast to the Tivoli radio that I use to amplify my music (embarrassing!) David and I got take out food from a Potbelly and ate lunch together in my office. Currently he is planning on joining my practice after finishing his general practice residency. Since he is using the matching program that most of the dental students use, he will not know where he will be doing his residency until match day which is in January sometime.  New York State requires that newly minted dentists either take part in a residency or practice in another state for a couple of years before th

 Usually cast posts are indicated for some anterior teeth after a root canal treatment,  especially if when these teeth are prepped for crowns the preparations leave minimal tooth structure. Since cast posts are made of metal they can be thinned as much as is needed, without weakening the core portion.  Another reason. that they are used is they can be fit to rather large oval root canal preparations that do not easily adapt to prefabricated round posts.  Cast posts are more expensive because they involve a laboratory fee and take two visits , while prefabricated post and cores can be completed in one visit and an impression for a crown can also be completed at this visit as well ( assuming that a long enough appointment is scheduled.  In my practice, I usually opt for a prefabricated post and core , assuming that it can be used without compromising the final result.  That being said, there are times when only a cast post will work  and I am forced to opt for this more labor intensiv

Dentistry is constantly evolving and an excellent dental practitioner has to be committed to life long learning.  I maintain a perfect five star rating on Google, teach at NYU College of Dentistry and really enjoy treating my patients. I continue to actively participate in over 100 hours of continuing education each year and I am a leader of a Spear Study Club that meets almost every month.   The writing on the wall clearly shows that our profession is transitioning away from making our patients porcelain fused to metal crowns as  practitioners are making a greater portion of their crowns all ceramic ( mostly either lithium disilicate or zirconium crowns).  I have become adept at utilizing these newer style restorations and am enjoying teaching the newer techniques to fourth year dental students at NYUCD.  Keeping up to date is an important part of producing predictably excellent results for our patients and during my lengthy career I have witnessed big changes in how dentistry is pe

We all are familiar with this cliche about the importance of early detection. Unfortunately because of their  COVID 19 concerns,  more people are delaying their recare dental visits, often waiting to schedule an appointment only when they notice a new dental symptom. Their choice may be  putting them at greater risk for infections and  the need for more extensive treatments.  In addition, many of the businesses that are located in Manhattan (my neighborhood) have not yet had their employees return to their offices for work full time.  Many of  my patients, who come in for  their checkup and cleanings,  are traveling from home which may require longer travel times to get to our office. Even if they are coming in to their offices part time, they may be loathe to take time off to visit us if cuts into their in person office hours. Not surprisingly when they do come in, my examinations are detecting more problems at more advanced stages than before the Pandemic.  Even if , as some exp

Why are monolithic Zironium crowns becoming the most popular type of crown for posterior restorations? Probably because they exhibit of a number of obvious advantages . These include the fact that cadcam zirconium crowns have more affordable lab fees, are more resistant to fracture, require less tooth preparation and more biocompatible than porcelains or the metals used in most dental restorations.  While earlier versions of full contoured zirconium crowns were often too opaque and less esthetic than a well made porcelain fused to metal crown, newer versions are more translucent and are esthetic enough to satisfy most patients who need posterior crowns. In addition, when their margins are supragingival, no grey collar is visible as often is the case with ceramometal restorations. Their margins can be placed either supra or sub gingival and unlike lithium disilicate restorations they can be cemented with resin modified glass ionomer or traditional dental cements without  sacrificing th

 Lately I have been utilizing tibased screw retained implant crowns, using original tibased prefab parts from the manufacturers. These are OK, but may sometimes be a problem. They only come in certain lengths and configurations for the titanium components. Sometimes the metal sleeve is too short to be retentive and sometimes the base of the part can be too close to the bone housing the implant, especially when the bone around the implant is at uneven levels. This can make torquing the implants down difficult since they are not passively fitting. I have become aware of an alternative to use in these situations which involve having a custom titanium abutment designed and milled to fit passively and then the lab cements on a milled zirconium crown with a hole in it. Voila, the resulting "screwmentable" restoration is better designed and more likely to fit passively.  I know my labs have been using Atlantis to mill these , but they may also be available by milling centers that

Dentistry can be expensive, especially when the dentist has to handle problems on an emergency basis. Many patients wait until something hurts them and often their pain is due to an infection that will necessitate a root canal or an extraction. Either way this scenario can easily become expensive since most teeth will need a post and/or core and a crown afterwards or in the case of an extraction, replacement teeth can cost more. Many of our patients have dental insurance that covers a high percentage of their dental work, especially for treatment plans that are less than $3000.  Most plans run on a yearly basis, ending on December 31. Since our patients often have long term, staged treatment plans. This allows them to do some of their planned work each year, in a way that maximizes the amount their dental insurance will contribute. Often they have "large interim fillings" that will function like "dental duct tape" to keep their teeth from becoming decayed, until

  Many denture wearers are excited to get their new dentures completed but often become frustrated when they have discomfort after they start to wear them. Some just take them out and give up on wearing them. This can be especially true of patients with new partial dentures that are replacing posterior teeth. It is unfortunate when this happens since most dentures can be made more comfortable by their dentists performing appropriate denture adjustments. There are a number of reasons that dentures need adjusting. Sometimes the bite is uneven and causes some pain and unintended loosening of the denture. Sometimes a denture border can be over extended, causing sores where the perifery contacts the mucosa. Other times the internal border is pressing on part of the patients maxilla or mandible that has an under cut and this can cause a sore to form from the excessive pressure.  Additional dentures sometimes need relieving because a part of the patient's ridge can't tolerate any

  Don't it always seem to go  that you don't know what you got 'til it's gone . These words from the Joni Mitchell song "big yellow taxi" may prove prophetic if Congress passes the new proposed expansion of the new Medicare bill to include dental. If this bill is passed and not carefully thought out it could cause a problem for my elderly patients, who may expect a continued high standard of dental care. Many dentists may choose not to participate, retire or sell their practices to more business oriented corporate entities.  Many private dental office have significant fixed overhead expenses that are often exceeding 70% of their collections and if dentistry is added to our medicare benefits, the deeply discounted fees that medicare may allow will discourage many dentists from participating.  If they choose to participate, they may change their operating procedures, in order to greatly increase the number of patients seen. Either way this may not be the type o

  My son David and his Best friend Maria are both fourth year dental students and NYU College of Dentistry. They have recently started their own dental blog- Aires and Caries  . He recently sent me a link to it and I am impressed. It's a great looking site.  They are certainly off to a good start with great photography and eight well written initial posts. I have been writing this blog since 2005 and have more than 1000 original posts. It hasn't always been easy coming up with ideas, and creating readable posts, but it has been both enjoyable and a worthwhile use of my time.  I feel proud that my son and his best friend are picking up the gauntlet and choosing to write their own dental blog. I am proud of their effort and and I wish them great success! from Ask Dr. Spindel - http://lspindelnycdds.blogspot.com/2021/09/aires-and-caries.html - http://lspindelnycdds.blogspot.com/

 The New York Times recently published an article " Five Decades later, Medicare might cover Dental Care"   This development would certainly help economically disadvantaged elderly patients better afford dentistry but it would likely restrict participating dentists to greatly reduced fees. I think it will most likely amount to "Medicaid Dentistry for the elderly". If this turns out to be the case, this may not be the type of coverage most of my elderly patients really desire, since Medicaid Dentistry amounts to triaged dental expenditures. Most patients who have significant dental problems  get covered for extractions and partial or full dentures, but not for more expensive dental options ( multiple implants and crowns)  In my dental practice,  elderly patients usually choose  to fix their teeth, even if crowns are needed and when their teeth need to be extracted they often opt for implant based replacements. Implant dentistry is not that inexpensive, especially

 My staff and I haven't taken time off since our Winter break at the end of 2020 and we are all happy to have two weeks off starting August 16th.  Last Friday was my last day teaching until September. Our office closed last week and we will reopen on August 30th. My son David and I will be in Woods Hole, Ma, a community I have been spending time almost every summer since 1959.  My father was a scientist and Woods Hole and we were fortunate to be able to spend entire summers there. Woods Hole is home to the Marine Biological Laboratories and also the Woods Hole Oceanographic Institute. Originally we went there so he could spend time researching at MBL, but we all liked it so much that we went there even when he wasn't at the MBL. We spent our summers at the beach, biking, fishing, playing tennis, and visiting with our summer friends. Last summer we decided on staying home during the pandemic and this summer I was also planning on a staycation, since I couldn't find a pl

Porcelain crowns and veneers 19 year post op  Most patients seeking a better smile seek guidance from their dentists on how to improve their smile. Most are already familiar with porcelain veneers since they have friends or family who have chosen this route. The esthetic results are often determined by the lab and the dentists mission is to prepare and impression their teeth properly. Usually the lab provides a cosmetic wax up done over the patients study model. This wax up can be used to dress rehearse the case prior to tooth preparation and can be used to fabricate good looking temporization as well. At least some of the esthetic decisions are determined with the help of the lab.  Patients seeking a treatment plan by a dentist about cosmetic dentistry would probably do best if they find a dentist equally familiar  with doing both esthetic restorations with composite as well as performing makeovers using veneers.  Often the resulting veneers look good, but somewhat "

  Patients often come into the NY University School of Dentistry where I teach to treat their dental emergencies. They often have a particular symptom that is bothering them. The students often want to address the symptom immediately, but often they are required, in non emergency situations, to first do a comprehensive exam and treatment plan.  It is not usual for these new patients at the school to initially express a resistance to taking a full set of radiographs and submitting to a full work up by their student. Often their student also wants to immediately care for the tooth thats bothering them, but our student dentists need to understand the importance of  performing a complete patient assessment prior to performing non emergency dental treatments.   Many problems that patients have are not terribly symptomatic, at least until that time when their conditions worsens and they are forced to seek "emergency care". For this reason and others, most of our emergency tre

 Traditionally dentists have been trained to provide a chamfer or shoulder of 1 mm if possible. For smaller teeth .75 mm might have been used in order to not overly weaken the remaining tooth structure. This amount of reduction was advisable because most of the crowns made were porcelain fused to metal crowns that needed this reduction to make room for both metal and porcelain materials. With the advent of adhesive dentistry, some dentists (myself included) used more minimal reduction strategies for anterior teeth. After all, only a .5 mm chamfer or shoulder is necessary to fabricate bonded feldspathic crowns. More reduction was needed where the restoration would be in occlusion, but at the neck of the prep restorative material is not under as much stress and shouldn't need as much thickness.While esthetics can sometimes dictate a greater reduction (especially in the case of a darker stump shade), most of the time .5-.75 reduction is all that is necessary.   Another considerat

 This is a somewhat strange tittle for a dental blog post, but more and more, when I examine my patients mouths I often feel like a gardener examining the flowering plants and shrubs that he has taken care of for years. My patients mouths, especially those who follow my recommendations have done quite well and even though many are over 70, they have retained most or all of their teeth. Alright, I should admit that I am fortunate to be practicing in Manhattan and many of my patients are relatively affluent compared to others. They feel like they can afford to come in frequently for recall and restore their teeth according to my recommendations.  Although treating caries and performing restorative dental procedures are part of my practice, education and preventive dentistry play a larger role in maintaining my patients oral health. I encourage all my patients to use an electric tooth brush, clean interproximally and have at least two cleanings per year. For many patients oral health ca

When my cousin came in for a cleaning she told me that she stopped using her electric tooth brush because she was experiencing vertigo. Her husband, a neurologist told her to stop using her electric toothbrush because it might be aggravating her vertigo (BPPV). By the time I saw her for her cleaning she had been using a manual brush for several months and her plaque control and gingivitis was worse than when she had been using her electric brush.  I did a little research on BPPV and one study found that of the patients who had BPPV 12% reported dizzyness after using their electric toothbrushes... Huh? The study did not conclude that people with BPPV should refrain from using electric toothbrushes  since " The results align with some publications demonstrating that vibrations in the head and neck area from the use of an electric toothbrush can initiate dizziness; however, it does not appear that this modality of vibration is significant for inducing recurrent BPPV. " Whi

 While all dentists strive to do fillings with good interproximal contact areas, it still is not uncommon for fillings to end up with less than ideal contact areas that can allow food to get stuck in between teeth that . While flossing can remove this food, sometimes the food gets lodged in the gingival sulcus that contact a tooth and this can lead to recurrent decay or periodontal bone loss. One of the most frequent complaints I hear from new patients involve food getting stuck between teeth. Sometimes the solution is replacing some of their fillings since redoing them can eliminate this problem. In some situations, where significant tooth structure is missing in the restored tooth, a crown maybe the best solution. Proper contacts are not that difficult to achieve , especially if the dentist uses a contoured metal band in conjunction with a V-3 ring ( a spring that pushes teeth apart and helps adapt the contoured band). Even when using this system, care must be taken to ensure th

  The New York Times has recently published an article titled " On Medicare and Need Dental Work? Beware a Big Bill" . The article pointed out correctly that standard Medicare plans don't cover most dental procedures unless they are related to the treatment of an ongoing medical problem. It also correctly explained that Medicare Advantage policies may cover some dentistry but they max out quickly if the patient the type of significant expenses involved with more extensive treatment plans involving implants.  The truth is that seniors are often on fixed incomes and are loath to spend what savings they have on significant dental plans. I have some personal experience with this subject since a very high percentage of my patients are over 65 and most of those are either retired or planning on retiring in the near future. While I participate in two dental plans ( Cigna PPO & Delta Premier) most seniors who retire are uninsured.  They often complain about the cost of d

 One hundred years ago the world suffered through a pandemic and WW I at the same time. When they were over, people were ready to celebrate and afterwards the Roaring Twenties ensued. People were in the mood for conspicuous consumption and partying to celebrate.   I t was a period of economic prosperity with a distinctive cultural edge in the United States and Europe, particularly in major cities   ]  M ost of my patients have been vaccinated and have been staring at their teeth during numerous Zoom sessions over the last year and they are often ready to contemplate cosmetic dental procedures when they have returned to my office. Often they are not as concerned over the cost, since many have saved money be cause they haven't been entertaining, traveling or taking vacations during  the last year. Also some patients have delayed needed dental treatments during the pandemic but are ready to get started, now that they are vaccinated and the Pandemic seems to be on the wane hear in the

 I've been a practicing dentist since 1980 and with the exception of my first three years in dental practice, I have worked in my own dental practice. Even when working for other dentists, I always maintained an independence. In my mind, my primary mission was to perform the best dentistry that I was capable of and maximizing my income was a secondary concern.  Early in my career I worked in a number of "lower fee" dental settings and I enjoyed working in these practices because they allowed me the opportunity to perform all sorts of procedures ( Crown and bridge, endodontics, periodontics,  dentures and fillings. Since few dentists graduate dental school being truly masters of all dental procedures, we have a need to perform many procedures before feeling truly confident in our ability to predictably practice excellent dentistry. Most seasoned dentists, when  asked  would agree that  it takes five to ten years to feel truly proficient in most of the procedures they per

Just today  the NY Times  quoted a study that showed that "The Pfizer and Moderna vaccines are 94 percent effective at preventing hospitalization in older adults".  Many of my patients are over 50 and most  are vaccinated.  More and more they are returning for their delayed dental care.  People are living longer and many expect to live past 80 years of age.  Jane Brody published an article in today's Tmes t hat  maintains that the "secret to a happy and vibrant life is to strive to do what you love for as long as you can". Since taking care of  teeth has been demonstrated repeatedly to improve ones health and quality of life, neglecting your teeth seems like a poor choice.  My office is located on 40th st between Madison and Park in a neighborhood that is sometimes called Murray Hill and sometimes Midtown East .  Things in the neighborhood are definitely picking up.  The foot traffic in our neighborhood seems to be increasing with each week and every since

 My office is located on 4oth st between Madison and Park in a neighborhood that is sometimes called Murray Hill and sometimes Midtown East. Our street seems to be located at the top of what is left of Murray Hill but it's hard to tell because most signs of the hill are missing, accept for a gentle slope visible along Madison Avenue.  Many of the stores and restaurants along Madison have closed and our choices for take out food are more limited than they used to be. My office is in a professional building and four of the seven suites on my floor are empty. There are only two tenants (Myself and another young dentist) who remain as tenants on the floor and other remaining dental office is sublet to a new dentist one day per week.  Possibly things are about to get better.  The foot traffic in our neighborhood seems to be increasing with each week and every since the CDC changed it's mask recommendations I have noticed more people going maskless while outside.   More of my pati

 I suspect that many dentists are noticing an increasing amount of new tooth decay in patients returning to their dental practices. The usual suspects maybe contributing explain this uptick. ..snacking on carbohydrates and sweets, poor oral hygiene and dry mouth are common contributing factors. I also have noticed an increasing number of cracked teeth and fillings that may have resulted from anxious patients bruxing and night grinding their teeth.  People who are working remotely or just "sheltering in place" may not feel the need to brush as often since they are not going to be in close contacts with people outside of their families and mask wearing will generally keep other people from noticing any offensive mouth odors. Staying at home may contribute the urge to snack since this helps eliminate boredom and lesson anxiety. Mouth breathing seems to be prevalent among mask wearers since most feel the need to increase the force of their air intake to overcome the filtering e

 Now that my patients are getting their vaccinations I have noticed an uptick in my booked appointments. In the last 30 days there has been an influx of longstanding patients who were over due and effectively missing in action. Most have been staying at home and reported that they decided to come in two weeks after their second vaccination.   My staff and I are happy to see these returnees and now that many  are vaccinated  and the days are getting longer our spirits are New Yorkers' spirits seem to be lifting. The subways are more crowded and the foot traffic in our midtown area is definitely increasing. While I am glad that New Yorkers are getting more comfortable in our city, many of them have put off their regular dental visits due to our pandemic. The truth is  that with or with out vaccination our office and most other dental facilities are safe spaces.  My office has air purifiers located through out and weather permitting we leave our windows slightly open to allow ev

There are two common ways of restoring implants, cementable and screw retained. Using the cementable mode a dentist uses a post that screws into the implant and then fabricates a crown that is cemented onto it. Screw retained crowns on the other hand screw directly into the implant and no cement is needed to be used in the patients mouth. There are advantages and disadvantages to each technique, but more and more dentists are preferring screw retained implant restorations since they are usually more retrievable ( easy to unscrew and remove if needed) and no excess cement can remain in a patients mouth that may cause future problems for an implant. The problem is that often implants are placed at angles that can make it difficult to fabricate conventional screw retained implant restorations because the screw hole would come out in a undesirable place ( on the buccal, lingual or proximal surface). Five years ago our best option for these implants was to fabricate either a custom impl

I received my second Moderna vaccine over a month ago.  I don't plan on dinning inside restaurants anytime soon and I still avoid crowded subway cars and shopping in crowded stores.   I believe that continued prudence in order. It is clear that a number of more contagious varients are around and spreading. Last week I had dinner at my son's apartment ( He and I have both been vacinated) for the first time in a year . It felt great to see him in person without us wearing masks.  That being the case, even though I have been fully vaccinated, I continue to double mask when I am treating patients and taking public transportation.   Also there is evidence that it is possible to get Covid a second time.  Its likely that those who are vaccinated may get a less severe form of Covid if they do come down with it ( a good thing!) but the best policy to follow is still exhibit some caution. Dr. Fauci believes that it is relatively safe for those who have been fully vaccinated to  sociali

  In 2005 I was going through a rather contentious divorce. I have to admit it affected my mood. I would meet every week end with my brother and we would  riff on movie ideas. I was in a somewhat unhappy place and most of my ideas were influenced by  my cynical state of mind but were funny, in a dark way.   We came up with an idea and a character called the "bad humor man" because both of tended to like dark humor jokes. Together we came up with a movie scenario involving the "bad humor man". He was either a doctor or an orderly whose wife had kicked him out of his house and now he walked into patients rooms and cracked cynical jokes sort of like Don Rickles. The patients initially would be angry but after awhile would look forward to his visits and invariably their condition would improve partly due to the "healing power of humor. I felt that the character would be like a dark version of Patch Adams. There was more to his story but that is not the point of