Bad Breath

Q: Recently my wife told me that my breath is bad. I'm not in any pain, but I haven't been to the dentist in about 6 years and I'm afraid of what he might tell me. F.R. - Smyrna

A: Having no pain is definitely better than having pain. So you're starting off on the right foot. It's more common for bad breath to be caused by a 'gum' or gingival problem than a tooth decay problem, so let's assume that your bad breath is a mouth related problem and talk about gums.

Even the best brushers and flossers need to have their teeth cleaned at a dental office periodically. Plaque sticks to your teeth continually. Those sweaters that you have on your teeth when you wake up in the morning are made up of old food and bacteria (plaque). Tarter is the 'petrified wood' of plaque. It's impossible for you to remove this tarter from the teeth. You can imagine that the longer this tarter and plaque stay on your teeth, the thicker they become and the worse your breath becomes.

A thorough deep cleaning may solve your problem. Be aware, however, that the longer the tarter stays on your teeth, the more infected your gums will become. Over time, the bone that holds your teeth in will melt away and you can eventually lose your teeth.

Even though your breath problem could be the result of a sinus, stomach, or metabolic problem, you seem to be starting in the right place. The sooner you see your dentist, the less damage will be done. Additionally, there are some new breath fresheners available at many dental offices that can give you almost immediate relief.


Dental Care

Q: I have a new baby. Is there anything special that I should do to make sure that she has good teeth? G.H. in Wilmington

A: This is a great question and I'll try to give you lots of general information. First, baby teeth are very important. Without them, it is difficult to chew, speak, and have proper facial development. Additionally, baby teeth are space maintainers for adult teeth. If baby teeth are lost early, the permanent teeth will come in crooked and be more likely to develop decay and gum disease.

Your child will get 20 baby teeth. A rule of thumb is that the first tooth comes in at about 6 months and she will get approximately 1 tooth per month for almost 2 years. However, I have seen babies born with 2 or more teeth and I have seen one year olds with no teeth. There is plenty of variation, so talk to your dentist if you have any concerns.

I strongly recommend breast feeding. It promotes good facial develop and helps to avoid allergy and airway problems. If you do bottle feed, use a NUK nipple, and never put your child to sleep with anything other than water in the bottle. When infants fall asleep with sugary solutions (or formula) in their bottle, the upper front teeth will decay very badly and may need to be removed.

From the day the first tooth comes in you have to keep it-and subsequent teeth-- clean. Simply using a wet wash cloth with no tooth paste is good enough until she gets older. Be prepared to brush and floss her teeth until she is 7-8 years old and has the dexterity to brush and floss for herself. Just like anything else, if you set a good example by taking good care of your own teeth, she will learn from your good example. That old saying, "do as I say, not as I do," won't work here.

At birth, the first permanent teeth are already beginning to form inside the bone. It is important that your baby get fluoride in her diet. Fluoride is an additive that will strengthen and protect the teeth. If the only source of nourishment for your child is breast milk, then you need fluoride supplements. Otherwise, check your well water, bottled water, and filter systems to investigate your water's fluoride content and contact your dentist or pediatrician for advice and/or supplements.

When your child gets older, avoid gum and candies that you suck on. These expose teeth to sugar over a longer period of time, cause decay, and can help wear out jaw muscles. Encourage your child to eat at meals and avoid too many between meal snacks.

The first dental visit should occur between 2 and 3 years old or sooner if you have a question or think that a problem may exist. By just showing an early interest in your child's health, you have taken a wonderful first step. Keep up the good work.

Q: My 5 year old son's grandparents bought him an electric toothbrush. Can it hurt his teeth? M.R.-Stanton

A: At the risk of offending a grandparent, electric toothbrushes can be terrific, but they are not always necessary. I am a big believer in training your child to use regular toothbrushes and floss. Once they can take care of their teeth properly anything that makes brushing more fun is great. But before you go out and buy an electric brush talk to your dentist.

While there are some very good brushes available, there are also some poorly made imitations out there. Your dentist will suggest a brush with a small brush head, proper cleaning motion, and good reliability.

Q: I have been getting my teeth cleaned two times per year for as long as I can remember. Recently my dentist asked me to come in more often. My insurance company only pays for 2 cleanings per year and I don't want to go more often than necessary. Do I need to go more often? L.W. in Odessa

A: This is a terrific and timely question. I'm not sure of your age or the health of your teeth so I will try to cover all of my bases.

You're right; there has been a tendency, for as long as I can remember, also, to clean our patients' teeth twice per year. The reason that I have always given is that it is difficult for major problems to show up if you are being seen every six months. Additionally, the insurance companies have decided that they will pay for two cleanings per year and dental offices have gotten tired of arguing with the insurance companies about the need to see their patients more often. Many patients have been reluctant to be seen more times than their insurance will pay and the dental offices don't like arguing with patients about insurance coverage.

So what is the real answer? If you have healthy teeth and gums and are taking good care of yourself I don't see any reason to be seen more than two times per year. During your visits the dentist and dental hygienist are looking for decay, gum disease, doing an oral cancer screening, and looking for other problems. I even ask my denture patients that don't have any teeth to come in at least once per year for a cancer screening. If your diet is good and you are flossing and brushing correctly you are unlikely to have any significant problems.

But what if you are older, have had previous gum problems or surgery? Maybe you are a diabetic or have an immune disorder. Maybe you just don't take great care of your teeth or maybe you have a history of heart attacks in your family. Now what do you do?

There is no perfect answer, but I can give you some guidelines. For many years we have told our patients that have had gum surgery that they need to be seen four times each year. It is important after surgery to keep your teeth cleaner than you did before your surgery. You can't have any 'slip-ups' or your going to loose your teeth. A little extra prevention is worth the extra time and expense if it means that you can keep your teeth.

Another important reason to go more often may be to prevent a heart attack. Recent studies have shown that high levels of inflammation in your body are twice as likely as high cholesterol to cause a heart attack. Chronic, long term gum disease is a significant source of inflammation that can help to cause blood clots that can lead to a heart attack. Your goal needs to be to get rid of low grade, long term gum disease and inflammation and if it takes a tooth cleaning every month or two it may be warranted.

As you can see, as long as your dentist has a good reason for more frequent visits I would go with his or her suggestion.


Dentures

Q: I am 55 years old and I have always had problems with my teeth. It seems that every time I get my teeth cleaned the dentist finds another problem. I'm thinking of having the rest of my teeth extracted and getting dentures. What do you think?

A: I think dentures are a terrific idea, unless you have any other options. You need to realize, however, that if you have your teeth extracted you would simply be trading the evil that you know for a whole list of new problems. If I had to guess, I would say that 10% of denture wearers love their dentures so much that they don't understand why they ever had real teeth.

Unfortunately, another 10% never get used to their new teeth no matter how many times they are remade. They will always eat soft foods and take their teeth out as soon as they get home. The remaining 80% do all right, but they have also helped create a huge denture adhesive market. The sticky denture adhesives help to keep the plastic dentures stuck to your gums so you can chew and smile.

Also know that dentures don't last forever. Most last 5-10 years. They will chip if dropped in the sink, begin to loosen over time so that they may slip and fall out, and they will wear out from everyday use.

If you have most of your teeth then you can probably eat anything you want without giving it a second thought. Most denture wearers can't bite with their front teeth and firm foods like steak, pizza crust, and Italian bread are a real struggle to eat. Many denture wearers are the last people to finish eating at the dinner table.

The cost of your new dentures, with extractions, will probably be $4-5,000.00. Wouldn't it be better to spend that money to keep your teeth?

So why should you spend all that money on teeth that always need dental work? Well, after 20 years, I have found that dental work that is properly planned, properly completed, and properly cared for will last.

Keeping good teeth is a balance between the good and the bad things that happen to your teeth and gums. You might have soft teeth that never had fluoride treatments, so you need to limit your sugar intake. You might be a diabetic, or epileptic, or have high blood pressure and take medicine that affects your gums, so you better not miss a day flossing. If you play ice hockey, you better wear a custom made mouth guard.

If you keep getting new decay, you're not brushing properly, your eating habits need to be checked, and you may need to re-evaluate whether your dental work is being done as completely as it needs to be. Are you following the dentist's suggestions or short changing your teeth with quick patches? Are you doing everything that is asked of you and you are still having problems? If you are completely convinced that you are doing everything correctly then maybe your dental work needs a second opinion.

There are definitely times when dentures are the best answer, but please don't get your teeth extracted out of frustration. Once your teeth have been extracted you can never go back

Q: I wear dentures. One dentist told me not to wear my dentures at night. Another told me to wear them all the time and not take them out. What should I do? M.G. in Talleyville

A: Both dentists were right, but for different reasons. I generally tell my patients to take their dentures out at night. I suggest to them that they would not leave their socks on 24 hours a day and that their 'gums' need to breath just like their toes. If you leave your dentures in all the time, you are much more likely to develop an infection under the dentures. However, I would be wrong not to tell you that my patients who leave their dentures in at night seem to have dentures that fit a little more securely and last a little longer. Unfortunately, this is probably because their 'gums' are a little swollen from being inflamed. If you have to leave them in at night, you need to at least be brushing the 'gums' that the dentures sit on, but taking them out at night is still the way to go.


Gum Disease

Q: I have 8 top teeth and 7 bottom teeth. I am 53 years old and my teeth have been getting looser and looser over the last 5-10 years. I know that I have gum disease, but I have been reluctant to have gum surgery because my older friends that had surgery lost their teeth anyway. I don't want to lose my teeth, do you have any suggestions? W.I. in Centerville


A: Yes, the faster you begin the better. I don't know how bad your gum disease is but I do have some direction and advice for you.

I am assuming that most of your remaining teeth are front teeth. Front teeth, especially weak front teeth with gum disease, cannot stand the pressure of chewing without back teeth for support. You will slowly destroy your front teeth if you can't chew on back teeth. So you need a plan. Either you keep the teeth you have, and add back teeth, or you remove all your remaining teeth and replace them all. Your dentist needs to make this decision with you and it will depend on where the remaining teeth are and how strong they are.

If you intend to save your remaining teeth you will need gum surgery. But don't have the surgery done unless you are going to change your brushing and flossing habits. Remember, the brushing, flossing, smoking, and eating habits that you have had for the past 30 years are the reason you need surgery today. You will continue to have gum disease (periodontitis) after surgery, and lose your teeth, unless you 'see the light'. I have seen teeth that I considered hopeless last for many years with proper treatment and homecare. You will need to replace your back teeth with implants or removable partial dentures to take the pressure off the front teeth.

If the loss of your teeth is inevitable or you just know that you're never going to floss, then you should consider full dentures or implants as soon as possible. The longer you leave the diseased and infected teeth in your mouth, the more bone you will loose in your jaw and the less bone you will have available to support your dentures or for the placement of implants later. The implants are metal supports that will secure your new teeth and help to prevent any more bone from melting away. At 53 years old you have over 20 years left before you get to your average life span. That is over 20 years of additional bone loss from your jaw. I am concerned that if you decide on full dentures you will become more and more dissatisfied with them as time passes and your jaw bone melts away.

The key to your successful treatment is a complete treatment plan with a strong foundation. The longer you wait, the less bone you will have, and the weaker your foundation will be.

Q: I am 55 years old and I have had severe gum disease for many years. My teeth aren't bothering me but my dentist said that I should consider having them extracted. Do you have any suggestions? J.T. in Hockessin

A: This is a very interesting question. Gum disease that is not under control will slowly progress until you have lost all of the bone holding in your teeth or you develop abscesses and the teeth have to be extracted. The signs of gum disease can be bad breath, bleeding gums, or shifting teeth.

The answer to your question lies in your own expectations. If you envision yourself with full or partial dentures (plastic teeth that are removable) you might be able to wait until your existing teeth hurt and then have them extracted. However, if you do not want removable teeth, and implants are an option for you, then it might be wise to start sooner than later. The important issue will be how much bone do you have left for the placement of implants and to build replacement teeth. Once an implant has been placed, your bone loss from gum disease will virtually stop. If you wait too long to place the implants you might not have enough bone left.

This is an important question and you should have a thorough understanding of your options.

Q: I am a 56-year-old woman and I had gum surgery 2-3 years ago. I thought that my gum problems were solved, but at my last dental visit I was told that I have 6 and 7millimeter pockets and I should have surgery again. I don't like the idea of having surgery again. Do I have any other options? S.T. in Newark

A: You do have some other options, but let me give you a little background first. The purpose of having 'gum surgery' is to make it possible to clean your teeth properly so that the teeth will last longer. The most important part of your teeth to keep clean is the space under your gums next to the teeth. Research has shown that if you're doing a great job of cleaning your teeth, you can clean 4 millimeters (about an 1/8 of an inch) under your gums. Unfortunately, if you have been neglecting your teeth, that space (or pocket) can get deeper.

Your dentist or dental hygienist should be measuring these pockets at each cleaning. As the pocket gets deeper, the bone that holds your teeth in starts to melt away and bacteria and food fester in the bottom of the pocket. These deeper pockets are impossible for you to keep clean and the problem continues to get worse. The disease is called periodontitis. If you have new 6-7mm pockets, you certainly need to be re-evaluated because your condition is getting worse. Remember that the purpose of the surgery was to make it possible to keep your teeth clean so that your deep pockets did not return.

Let's assume that you have been taking great care of your teeth but the gums and bone keep melting away. What are some other potential risk factors? Do you have a family history of gum disease? Diabetes and smoking can also make your 'gums' worse. Another possible problem is the way that your teeth come together. If your 'bite' is bad, or you have lost a few back teeth, you may be putting too much stress on the remaining, already weak, teeth.

So how can you avoid a second surgery? You may not be able to but here are some thoughts. Make sure that you're doing everything that you can to keep your teeth clean between dental visits. Your dental hygienist should be very helpful here. Don't be afraid to make a visit just to check your home care progress. The small cost of preventive care can save you thousands of dollars in treatment later. You should have been getting your teeth cleaned at least 4 times per year since your surgery. If not, it is time to get scheduled.

Sometimes patients have very aggressive bacteria attacking their gums. A periodontist can diagnose this problem and prescribe the correct antibiotics. If you're missing a bunch of back teeth, it is time to replace them so that you don't 'stress out' the remaining teeth. Years of periodontitis help to create 'nooks and crannies' between your teeth and areas of infection that you can't reach with your brush and floss. It is sometimes necessary to do 'deep cleanings' with anesthetic at your dentist's office to reach these areas. Also, a new medication (Periostat) is available that can greatly reduce the harm that the bacteria around your teeth is causing.

Obviously there are many pieces to the 'gum disease' puzzle. A thorough evaluation and treatment plan should help to extend the life of your teeth.

Q: I am 48 y.o. and my husband is 53 years old. He recently returned from the dentist where they said he has gum disease. He has never taken very good care of his teeth, but now I am afraid that it may be contagious. Am I going to get gum disease also? F.R. in Newark

A: The short answer is no, but what you are really asking is how do you get gum disease? As you might expect, bacteria or germs, are primarily responsible for causing gum disease. So I can see why you might think that it is contagious. However, we have all been exposed to these various bacteria at some point in our life. So why do some people get gum disease and others don't?

Gum disease comes in many types but for our purposes lets talk about gum disease where the damage is reversible or irreversible. When a person gets red, irritated gums (gingivitis) that can be cleaned up and returned to their original healthy state, the damage is reversible. The longer the disease, irritation, or 'risk factor' is present, the greater the chance that the gingivitis will turn into periodontitis where the gums recede and the bone that holds the teeth in will melt away. You can stop the progression of periodontitis, but you generally can't get back what you've lost. The same bacteria that can cause your gum disease can also cause bad breath or halitosis.

The number one reason that people get gum disease is poor home care -- it comes back to brushing and flossing. even if you have a number of other risk factors working against you, if you keep your teeth clean enough, you will probably do OK.

One of the greatest risk factors that I have seen is smoking. Smokers almost always have gum problems, and when they stop, I have seen incredible improvements. People who are diabetic have more fragile gums than most people, but if they do a great job of caring for their teeth, there is no reason to worry.

I have had many patients over the years tell me that their parents and grandparents lost their teeth from gum disease and the patient would be happy just to hang on to his or her teeth as long as possible. There is definitely an inherited or genetic part to some gum disease but what I think really happens is that the grandparents taught the parents and the parents taught them how to care for their teeth. So the poor home care was passed from generation to generation. Generally speaking, even if you have a family history of gum disease, you dentist can show you how to keep your teeth for you whole life.

Some seizure and heart medications can effect your gums, but your dentsit will know which medicines cause these problems.

Poor health, immune disorders, and even grinding your teeth can hurt your 'gums' but these aren't conditions you "catch". If your spouse is getting the right treatment and following the dentist's advice, he has a good chance of having healthy teeth, good breath, and a nice smile.

Q: It has been a number of years since I have been to the dentist. Recently, I went because my wife made me go and my teeth are getting a little stained, probably because I smoke. After the x-rays the dentist told me that my gums were infected and I needed some fillings. I told him that nothing hurts and I don't know why I need fillings and 'deep' cleanings. My wife wants me to go back but I don't want to waste the money. What do you think?

A: I think that you should listen to your wife (I always do). Women use the health care system better than men. They are more likely to seek preventative care and are also more likely to care for existing problems. I would guess that 75% of my patients are women.

Your dentist is also correct. Pain is not a good indicator of problems in your mouth. A good example is cancer. When cancer first starts in the mouth there is rarely any pain or discomfort associated with it.

When it comes to gum disease, pain is usually one of the last indicators of problems. It is much more likely that you will have bleeding or receding gums, loose teeth, or bad breath. By the time your gum disease (or infection) becomes apparent you might very well need surgery or extractions. Early on in the gum infection process, it is very likely that a 'deep cleaning' with anesthesia, followed by good homecare, can take care of the problem. The longer you wait, the more likely you will lose the bone that holds your teeth in, and the more difficult it will be to fix the problem.

Decay can be just as sneaky as gum disease. Early (or incipient) decay can not be felt and it can't be seen when it starts between your teeth. It is very common to have decay between your teeth if you are not flossing. Early signs of decay might be sensitivity to cold liquids or sweets. If hot food is bothering your teeth, it is sometimes a sign that the nerve in your tooth is sick and a root canal may be needed.

The reason that you should go to your dentist regularly and have x-rays taken is to catch problems so early that you don't know that they are there. The earlier that you find decay or gum disease the easier the treatment will be. The smaller the decay, the smaller the filling will be to get rid of the decay. Small fillings cost less and last longer than big fillings. Large areas of decay become root canals and crowns or can lead to tooth loss. Early gum disease can be corrected with a routine dental cleaning. Advanced gum disease can lead to more involved procedures like surgery, tooth extractions, and implant placement.


Internal Reabsorption

Q: What is internal resorption?

A: Internal resorption is a diagnosis dentists make when looking at a dental x-ray of your tooth. On rare occasions it can appear as though the inside of the tooth is melting away or resorbing. I called Dr. Dan Kreshtool and asked his advice on this one. Dr. Kreshtool is a root canal specialist and had the latest information for me.

He said that true internal resorption is actually very rare and often miss diagnosed. In cases of true internal resorption it is easily treated, when caught early enough, with a root canal. It seems that most cases of internal resorption are actually external resorption where the outside of the tooth has actually melted through the tooth.

External resorption is difficult to treat successfully, but can be treated by surgically placing a filling on the problem area. Sometimes doing nothing is better than aggressively treating the affected tooth. External resorption is thought to be due to some form of trauma.


Osteoporosis

Q: I recently had a hysterectomy and I am on hormone therapy to prevent osteoporosis. Should I be worried about bone loss around my teeth and gum disease? J.P. in Newark

A: If you are on 'hormone' or estrogen replacement therapy, you had a total hysterectomy (your uterus and both your ovaries were removed). Your operation created a 'surgical menopause' that is now being controlled by your estrogen replacement. As long as estrogen levels are maintained, you will not develop osteoporosis and the hysterectomy will not cause gum and bone disease in your mouth. I spoke to Dr. Barry Kayne (a gum specialist in Wilmington). Dr. Kayne said that a direct link between osteoporosis and gum disease is under investigation and the information at this time is inconclusive.

My suggestion is that if you have uncontrolled osteoporosis, you should have your dentist examine your teeth to make sure that the gums and bone around your teeth are healthy. Also, if you are post-menopausal and you have significant bone disease, you should have your physician do a bone density test to make sure that you are not having any of the symptoms of osteoporosis.


Periodontitis

Q: I am a 55 year old female. I have a history of both osteoporosis and periodontitis (gum disease) in my family. Are these two diseases related and can anything be done to keep me from losing my teeth? T.M. in Wilmington

A: A patient of mine recently asked me a similar question. I told her that I had been practicing for 20 years and I had never heard of an association between these two diseases. But new research is being done all of the time, so I did a little digging and found that I was wrong. There is an association between osteoporosis and advanced gum disease or periodontitis. Unfortunately, the results of the research are not as clear as we might like.

Periodontitis is an advanced gum disease characterized by swollen or receding gums, a bad taste in your mouth, or bad breath. You can also have loose teeth, pain, drainage, or pus around one or more of your teeth.

I wish that I knew more about osteoporosis, but I think that most of us know that this is a disease of the whole body associated with low bone density. It is most common among post-menopausal women and can be treated with calcium supplements and hormone replacement therapy.

It is only logical to associate bone loss in the body with bone loss around your teeth. So we try to study women that have gum disease with and without osteoporosis (not at all easy). What has been found is that osteoporosis may be an increased risk factor for gum disease (bone loss). But if you take great care of your teeth (brush and floss), you are much less likely to have any gum problems.

However, if you are in your fifties and have recently discovered gum disease, you might ask yourself some questions. Have I been taking good care of my teeth and do I have a history of gum disease in my family? If you feel good about the answers to these questions then you might consider seeing your family doctor. In addition to osteoporosis there are a number of other problems that you might have that are associated with gum disease.

Gum disease can sometimes be a warning sign for other problems that you may be having. Although it is not unusual for patients to have a family history of gum problems, medications (especially medicines that cause a dry mouth) can put you at increased risk. Tobacco use (both cigarettes and smokeless), diabetes, and pregnancy (hormone changes) can also increase your chances of having gum disease. Lastly, any illness or medications that decrease your body's immune system and increase your risk of infection can lead to periodontitis.

Q: I had gum surgery a couple of years ago. Since that time my dentists have recommended cleanings four times a year. My insurance only pays for two cleanings a year. How important are the extra cleanings? J.A. in Stanton

A: Anytime gum surgery is performed, the 'extra' cleanings are necessary and not extra. Please don't let your insurance contract stand between you and good dental care. The additional cleanings can keep you out of trouble and away from future surgery. If you fail to take good care of your gums you will lose the bone that holds your teeth in and you can lose your teeth. The insurance companies have never examined or treated you and the people that wrote the dental insurance contract do not have the education or experience to make a diagnosis and recommend a course of treatment.


Selecting a Dentist

Q: I paid a lot of money for a lot of dental treatment recently. After numerous attempts to fix problems, I am unhappy with both the result of the treatment and the dentist. What should I do?

A: This brings up so many topics for conversation that I think I'll write a book. Are your expectations too high, did you do less treatment than was recommended, should you get your money back, should you get an attorney, what other options do you have?

Now that treatment is completed you can either decide to be satisfied with the treatment or have it redone. If you decide to be retreated, it will be costly, and you may or may not get your money back from the first dentist. Was there a guarantee that you would be satisfied? Did you do everything that was required of you? Did you follow all the dentist's instructions and keep your appointments? If you can answer all these questions and you are still sure that you have been treated unfairly, then you should probably do some serious searching for a dentist with expertise in the area of your treatment needs. Additionally, as a last resort, I would call the Delaware State Dental Society to inquire about their 'Peer Review' process to help solve dental treatment disputes.

I have found that attorneys generally don't like handling dental disputes. There doesn't seem to be enough money involved to allow for attorney's fees and a happy dental patient at the end of the process.

Remember, all plumbers, painters, dentists, and race car drivers are not the same. It is sometimes difficult to separate marketing claims from actual experience. Over the years, my advice to those searching for a dentist has been to find a good, honest person. Not 100% of any procedure works every time. But if you are working with the right dentist, he will care enough about you to make sure that you spend your money wisely, that he treats you within the limits of his education, and that you are happy at the end of the treatment.

Q: I told my wife about the nurse that helped me at my dental office. She told me that dentists do not have nurses in their offices. Who is right?

A: You have indirectly given me an opportunity to brag a little about my staff. I am assuming that you are talking about your general or family dentist. If you are speaking of an oral surgery office it is possible that a nurse may be working there in order to dispense medications and assist the surgeon, but in a general dentist office is very unlikely that a 'nurse' is on staff.

Dental offices usually have three staffing areas; dental hygiene, dental assisting, and the front desk. The dental hygienists are the staff members that clean your teeth. They usually have gone through a 2-4 year college hygiene program and are licensed by the State to do certain procedures. The hygienists in my office have taken extensive continuing education and are capable of finding growth and development problems, early decay and gum disease, and can help detect and evaluate your medical history and condition.

Dental assistants work very closely with the dentist and are indispensable for most procedures. Dental assistants can be certified, non-certified, or expanded duties. In Delaware there is no formal training or licensing requirements for assistants, but if you were to talk to the assistants in my office you would find that they are extremely knowledgeable in almost all areas of dentistry and a wealth of information.

The front desk staff has a very broad and impossible job. It is the 'front desk's' responsibility to make sure that everyone is happy. They must juggle difficult schedules, understand financial arrangements, be a wizard on the computer, deal with impossible insurance plans and problems, and generally remember a special request by all 2500 patients.